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School of Dentistry

Faculty of Medicine and Health

Restorative Dentistry Clinical Handbook


Introduction
and contents

Restorative
Clinical
Procedures

Prosthetics

The Clinics

General
Clinical
Working
Practices

Student
Supervision

Periodontology
Appendix

Quick Link Menu


Treatment
planning

Radiographic
assessment

Materials
quick guide

Step-by-step
procedures

Version 2.2
April 2014

School of Dentistry

Faculty of Medicine and Health

Restorative Clinical Procedures


Record keeping

Guidelines for RCT

History, exam, diagnosis


& treatment plan

Guidelines for the


restoration of RCT teeth

Preoperative
considerations

Crowns and extracoronal restorations

Routine restorations

Bridges

Back to main menu

School of Dentistry

Faculty of Medicine and Health

Routine restorations
Step-by-step guide

Caries removal
Amalgam

Root canal treatment

Protocol and guidelines


Access
Cleaning and shaping

Resin composite

Modified double
flared technique

Bulk fill (SDR)

ProTaper hand file


technique

Restoration of RCT teeth

Rotary endo
ProTaper technique

Step-by-step guide

Crowns

Preparation criteria
Dentine bonded
crown (anterior)
Metal ceramic
crown (anterior)
Full veneer crowns
(posterior)
Metal ceramic
crown (posterior)

Bridges

Principles of preparation

Nayyar core

Obturation

Prefabricated post
& core

Back to main menu

Resin bonded
bridge

School of Dentistry

Faculty of Medicine and Health

Removable Prosthetics Clinical Handbook

Clinical Stages

Aide Memoirs

History, exam, diagnosis &


treatment plan

Wax try in

Evaluation of the patient and


dentures

Disinfection and infection


control

Fitting the dentures

Primary impressions

Preliminary impressions &


special tray request

Advice to the patient

Secondary impressions

Partial denture design

Review

Recording the occlusion

Working impressions

Immediate dentures

Wax try in

Trying the framework

Copy dentures

Fitting the dentures

Recording the occlusion

Reline / Rebase

Partial denture design

Back to main menu

Back to main menu

Contents / Full index

Restorative Dentistry Clinical Handbook


Version 2.2 - April 2014
Edited by

P. Franklin
Senior Clinical Teaching Fellow
G. Simon
Clinical Teaching Fellow

Introduction ............................................................................................................................................................. A-1


For students ......................................................................................................................................................... A-1
For clinical members of staff ............................................................................................................................... A-2

Contents .................................................................................................................................................................. A-2

Introduction
The latest version of this handbook has been specially developed for visualization in tablets. Navigation is also
possible through computer and smart phone platforms.
Intuitive menus with hyperlinks are disposed throughout the document to make this a quick tool for information
finding. Interactive tables (checklist in Prosthetics - Aide Memoirs) are also available, please note that every time
these are used, when exiting the document, you will be asked if you would like to save it, please select "no".
When opened for the first time the document will try to force full screen mode, please select 'Remember my choice
for this document' and press 'Yes' for optimum navigation.
Printing a hard copy is also possible but we encourage our students to think green and we, as an innovative
institution, believe that technology should be used in teaching & learning to enhance the full potential and
experience of our students.
This book has been created as an introduction to the clinics at Leeds Dental Institute. Whilst trying to be
comprehensive it is necessary to also be succinct and so the detail may be brief in areas.
It is the nature of publishing in the clinical field that developments in materials and techniques can quickly make any
published work seem dated and obsolete. For this reason this document will be updated annually, the most current
version will be available on both clinics and online.

For students
Your clinical experience is extremely important, both to you and your patients. We are very proud of our students at
Leeds and the treatment they provide. For this reason we have to establish and maintain a set of standards that both
ensure patient safety but also set you on the right road to successful clinical practice. This book gives an outline, no
more than a reminder of standards and accepted practices. Preparation for clinics is vital, you will be expected to be
A-1

well versed in the materials and techniques you are proposing to undertake or use each session. For this purpose
this manual alone will not be sufficient and reading of the recommended texts is extremely important.

For clinical members of staff


The following notes have been prepared to assist you with your teaching responsibilities and to give you some
guidance on department policy on a range of clinical and organisational issues. Should anything remain unclear
please do not hesitate to ask clinical colleagues.
A general Staff Room is available on Level 6 and there is a canteen adjacent to the Student Common Room where
refreshments can be obtained. There is a further canteen on Level 7.
Our dental undergraduates spend a high proportion of their time in these clinics from first year onwards. In addition
the 4th and final years will visit out-reach clinics at Beeston, Bradford and Hull. It is important therefore to know
about:

The clinic working arrangements.


The facilities of the clinics including the emergency and safety provisions, and
The equipment and how it works.
The procedures and techniques that our students are taught.

Contents
Introduction ............................................................................................................................................................. A-1
For students ......................................................................................................................................................... A-1
For clinical members of staff ............................................................................................................................... A-2

Contents .................................................................................................................................................................. A-2

The Clinics ................................................................................................................................................................. B-2


Equipment .................................................................................................................................................................. B-2
Operators cabinetry................................................................................................................................................... B-3
The dental chair ......................................................................................................................................................... B-5
Chair movement .................................................................................................................................................. B-5
The footswitch ..................................................................................................................................................... B-7
Dental operating light .......................................................................................................................................... B-7
Chair-mounted spittoon / suction unit ................................................................................................................ B-8
Headrest ............................................................................................................................................................ B-10
Operators control module ................................................................................................................................. B-11
Safety notes ....................................................................................................................................................... B-12
Assistants control panel..................................................................................................................................... B-13
3 in 1 syringe ...................................................................................................................................................... B-14
A-2

Latex safe areas ................................................................................................................................................. B-14


Student attendance ................................................................................................................................................. B-14
Clinic hours and appointments ............................................................................................................................... B-15
Patient appointment bookings .......................................................................................................................... B-15
Patients failing to keep appointments............................................................................................................... B-15
Treatment of patients.............................................................................................................................................. B-16
Responsibility for patient care ........................................................................................................................... B-16
Transfer of patients ........................................................................................................................................... B-16
Referral of patients ............................................................................................................................................ B-17
Professional conduct and patient management .................................................................................................... B-17
Dress code.......................................................................................................................................................... B-17

General Clinical Working Practices................................................................................................................ C-2


Infection prevention and control .............................................................................................................................. C-2
Standard precautions .......................................................................................................................................... C-2
Hand hygiene ....................................................................................................................................................... C-2
Personal protective equipment (PPE).................................................................................................................. C-2
Safe sharps management and inoculation injury awareness .............................................................................. C-3
Waste disposal ..................................................................................................................................................... C-4
Containers ............................................................................................................................................................ C-4
Disinfection and cleaning of body fluid spillages................................................................................................. C-5
Hazardous spillages ............................................................................................................................................. C-6
Cleaning dental unit prior to use............................................................................................................................... C-6
Student summary sheet for cleaning unit prior to use ............................................................................................ C-6
Student summary sheet for preparing unit for use .................................................................................................. C-8
Asepsis........................................................................................................................................................................ C-9
Personal illness .......................................................................................................................................................... C-9
Equipment failure / breakdown ................................................................................................................................ C-9
Accidents and emergencies ..................................................................................................................................... C-10
Fire ..................................................................................................................................................................... C-10
Sudden collapse of an individual ....................................................................................................................... C-10
Medical emergencies training for the dental team ................................................................................................ C-11
Medical emergencies drugs and equipment ..................................................................................................... C-11
Medical emergencies audit................................................................................................................................ C-11
Medical emergencies training ........................................................................................................................... C-11
Reporting of incidents ............................................................................................................................................. C-12
A-3

Dispensary facilities ................................................................................................................................................. C-12


Cleansing and return of used instruments ........................................................................................................ C-12
Protocols for using instrument kits in all clinical departments ............................................................................. C-13
The role of the dental nurse .................................................................................................................................... C-14
Transport patients ................................................................................................................................................... C-14
Hospital laboratory .................................................................................................................................................. C-15
Endodontic x-Ray facility ......................................................................................................................................... C-16
Prescriptions ............................................................................................................................................................ C-17

Student supervision........................................................................................................................................... D-1


Briefing / debriefing ............................................................................................................................................... D-1
Student assessment ................................................................................................................................................ D-2
Log books .......................................................................................................................................................... D-2
Cause for concern ................................................................................................................................................... D-5
Sessional grade ................................................................................................................................................. D-5
End of Term Reviews .............................................................................................................................................. D-7
How Our Undergraduates Are Taught ................................................................................................................... D-7
Clinical Allocations .................................................................................................................................................. D-9
Examinations in Restorative Dentistry ................................................................................................................ D-10

Restorative Clinical Procedures


Record keeping.......................................................................................................................................................... E-1
Dental hospital records and treatment .................................................................................................................. E-1
Consent ................................................................................................................................................................... E-1

History, examination, diagnosis and treatment plan ......................................................................................... F-2


History .................................................................................................................................................................... F-2
Referral (Ref)...................................................................................................................................................... F-2
Complaint of (C/O) ............................................................................................................................................. F-2
History of the presenting complaint (HPC) ........................................................................................................ F-2
Past dental history (PDH) ................................................................................................................................... F-2
Social history (SH) .............................................................................................................................................. F-2
Medical history (MH) ......................................................................................................................................... F-2
Charting .................................................................................................................................................................. F-2
Examination............................................................................................................................................................ F-3
Periodontal screening ........................................................................................................................................ F-3
Extra-oral examination ...................................................................................................................................... F-3
A-4

Occlusion............................................................................................................................................................ F-4
Dentures ............................................................................................................................................................ F-4
Special tests ....................................................................................................................................................... F-4
Radiographic report ........................................................................................................................................... F-4
Diagnoses................................................................................................................................................................ F-4
Treatment Plan ....................................................................................................................................................... F-4
The likely sequence............................................................................................................................................ F-5
Emergency treatment................................................................................................................................... F-5
Pre-treatment baseline indices and records ................................................................................................ F-5
Stabilisation phase ........................................................................................................................................ F-5
Initial reassessment ...................................................................................................................................... F-6
Definitive treatment ..................................................................................................................................... F-6
Continual review and maintenance.............................................................................................................. F-6

Preoperative considerations.................................................................................................................................. G-1


Moisture control ................................................................................................................................................... G-1
Rubber Dam........................................................................................................................................................... G-1
Matrix and wedging .............................................................................................................................................. G-2
Facebow recording ................................................................................................................................................ G-3
Interocclusal records ............................................................................................................................................. G-3
Choice of articulator.............................................................................................................................................. G-4

Routine restorations ............................................................................................................................................... H-2


Choice of restorative materials.............................................................................................................................. H-2

Caries removal (equipment required & step-by-step guide) .............................................................................. H-3


Amalgam .............................................................................................................................................................. H-4
Occlusal amalgam ............................................................................................................................................ H-4
Approximal amalgam ........................................................................................................................................ H-4
Equipment required & step-by-step guide ....................................................................................................... H-4
Bonded amalgam ............................................................................................................................................. H-6
Replacement amalgam .................................................................................................................................... H-6
Carving .............................................................................................................................................................. H-6
Polishing............................................................................................................................................................ H-6

Resin composite .................................................................................................................................................. H-7


Case selection and management ...................................................................................................................... H-7
Shade taking ..................................................................................................................................................... H-7
Equipment required & step-by-step guide ....................................................................................................... H-8
A-5

Bevelling............................................................................................................................................................ H-9
Bonding ............................................................................................................................................................. H-9
Composite placement ....................................................................................................................................... H-9
Finishing and polishing ................................................................................................................................... H-10
Core build up................................................................................................................................................... H-10
Bulk fill composite (SDR - Step-by-step guide) ............................................................................................... H-10

Glass ionomer cements .................................................................................................................................. H-12


Shade taking ................................................................................................................................................... H-12
Use and indications......................................................................................................................................... H-12
Traditional glass ionomer cement (GIC) .................................................................................................... H-12
Resin Modified glass ionomer cement (RMGIC)........................................................................................ H-12
Dentine conditioner (cleansing) ..................................................................................................................... H-12
Trituration / mixing ......................................................................................................................................... H-13
Matrix.............................................................................................................................................................. H-13
Finishing .......................................................................................................................................................... H-13
Core build up................................................................................................................................................... H-13

Clinical guidelines for bases / liners ................................................................................................................... H-14


Liners .................................................................................................................................................................... H-14
Pulpal exposure.................................................................................................................................................... H-14

Pulp protection materials available in the department ................................................................................. H-14


Setting calcium hydroxide (Dycal)........................................................................................................................ H-14
Non-setting calcium hydroxide (Hypocal)............................................................................................................ H-14
Glass ionomer cement (Fuji Liner) ....................................................................................................................... H-14
Bonding systems (Optibond solo Plus) ................................................................................................................ H-14
Ledermix ................................................................................................................................................................... H-14
Kalzinol (zinc oxide eugenol) ..................................................................................................................................... H-14

Guidelines for root canal treatment (RCT) ............................................................................................................ I-2


Preoperative considerations .............................................................................................................................. I-2
Single visit / multi-visit........................................................................................................................................ I-2
Materials and equipment ................................................................................................................................... I-3
Preoperative assessment.................................................................................................................................... I-4
Rubber dam ........................................................................................................................................................ I-4
Irrigation ............................................................................................................................................................. I-4
Recapitulation ..................................................................................................................................................... I-4
Endodontic radiography ..................................................................................................................................... I-5
A-6

Working length determination ........................................................................................................................... I-5


Working length radiograph................................................................................................................................. I-6
Root morphology ................................................................................................................................................ I-6

Access ..................................................................................................................................................................... I-8


Anterior teeth - Maxillary and mandibular ......................................................................................................... I-8
Premolars - Maxillary and mandibular ............................................................................................................... I-8
Molars - Maxillary ............................................................................................................................................... I-9
Molars - Mandibular ........................................................................................................................................... I-9

Root canal cleaning and shaping ..................................................................................................................... I-10


Modified double flared technique .................................................................................................................... I-10
ProTaper hand file techinque ........................................................................................................................... I-11
Rotary endodontics - ProTaper techique.......................................................................................................... I-12
Preparation of curved canals using ProTaper files ........................................................................................... I-13

Root canal obturation ........................................................................................................................................ I-13


Obturation ........................................................................................................................................................ I-13
Inter-appointment medication and temporisation of access cavity ..................................................................... I-13
Endodontic retreatment ....................................................................................................................................... I-14
Problems arising during endodontic treatment................................................................................................... I-14
Hypochlorite ..................................................................................................................................................... I-14
Perforation ........................................................................................................................................................ I-14

Guidelines for the restoration of root filled teeth ...............................................................................................J-1


The ferrule ...............................................................................................................................................................J-1
Posts.........................................................................................................................................................................J-2
Core build-ups .........................................................................................................................................................J-2
The need for crowns ...............................................................................................................................................J-2
Summary for anterior teeth ....................................................................................................................................J-2
Summary for posterior teeth ..................................................................................................................................J-2
Nayyar core technique - Step-by-step guide ..........................................................................................................J-3
Prefabricated fibre post and core - Step-by-step guide.........................................................................................J-4

Crowns and extra-coronal restorations ................................................................................................................ K-2


Prescription ............................................................................................................................................................ K-2
Preparation adequacy ............................................................................................................................................ K-2
Crown margin positioning...................................................................................................................................... K-2
Crown lengthening ................................................................................................................................................. K-2
Study casts and articulators ................................................................................................................................... K-2
A-7

Multiple crown cases ............................................................................................................................................. K-2

Temporary crowns............................................................................................................................................... K-3


Temporary crown cementation ......................................................................................................................... K-3

Types of Crowns ................................................................................................................................................... K-3


Anterior .............................................................................................................................................................. K-3
Dentine bonded crowns .............................................................................................................................. K-3
Metal ceramic crowns (MCC) ...................................................................................................................... K-4
Posterior ............................................................................................................................................................ K-5
Partial veneer crowns .................................................................................................................................. K-5
Full gold (full veneer crowns - FVC) ............................................................................................................. K-5
Metal ceramic crowns (MCC) ...................................................................................................................... K-6

Impressions........................................................................................................................................................... K-8
Gingival tissue management for impressions.................................................................................................... K-8
Custom vs. stock trays ....................................................................................................................................... K-8
Impression Materials ......................................................................................................................................... K-8
Adequacy of impressions.............................................................................................................................. K-8
Occlusal registrations and opposing arch impressions...................................................................................... K-8
Ceramic shades....................................................................................................................................................... K-9
Trial fitting of crowns ............................................................................................................................................. K-9
Occlusal checking ................................................................................................................................................... K-9
Management of a 'high' crown ........................................................................................................................ K-10

Cementation ....................................................................................................................................................... K-10


Zinc phosphate ................................................................................................................................................ K-10
Resin composite............................................................................................................................................... K-10
Resin modified glass ionomer .......................................................................................................................... K-10

Follow up - Review ............................................................................................................................................ K-10


Bridges ........................................................................................................................................................................ L-2
Treatment planning................................................................................................................................................ L-2
Use of articulators .................................................................................................................................................. L-2
Selection of abutment teeth .................................................................................................................................. L-3
Resin bonded bridges (RBB)................................................................................................................................... L-3
Patient assessment, diagnosis and treatment planning .................................................................................... L-3
Indications / contraindications .......................................................................................................................... L-3
Bridge design ..................................................................................................................................................... L-3
Framework design ............................................................................................................................................. L-3
A-8

Clinical stages .................................................................................................................................................... L-4


Preparation ................................................................................................................................................... L-4
Principles of preparation .............................................................................................................................. L-4
Impressions................................................................................................................................................... L-4
Try in ............................................................................................................................................................. L-4
Bonding of RBB ............................................................................................................................................. L-5
Conventional bridgework ...................................................................................................................................... L-5
Types of bridges ................................................................................................................................................ L-5
Fixed-fixed .................................................................................................................................................... L-5
Fixed-moveable ............................................................................................................................................ L-5
Cantilever...................................................................................................................................................... L-5
Spring cantilever ........................................................................................................................................... L-5
Luting agents for conventional bridgework ..................................................................................................... L-6

Summaries
Radiographic assessment .............................................................................................................................. M-1
Introduction ............................................................................................................................................................. M-1
Selection criteria for radiographs ........................................................................................................................... M-1
Diagnosis of dental caries ................................................................................................................................... M-1
Assessment of periodontal disease .................................................................................................................... M-1
Guidelines on writing a radiographic report .......................................................................................................... M-2
Example of radiographic report ............................................................................................................................... M-3

Quick guide to restorative materials ............................................................................................................. N-1


Introduction................................................................................................................................................................ N-1
Permanent and temporary restorative materials .................................................................................................... N-1
Amalgam ................................................................................................................................................................ N-1
Chemfil Rock (GIC) .................................................................................................................................................. N-2
Fuji Triage (GIC) ...................................................................................................................................................... N-2
Fuji II LC (RMGIC) .................................................................................................................................................... N-2
Bases / liners .............................................................................................................................................................. N-2
Fuji Lining (RMGIC) ................................................................................................................................................. N-2
Dycal (setting calcium hydroxide) .......................................................................................................................... N-3
Luting cements ........................................................................................................................................................... N-3
Fuji Plus (RMGIC) .................................................................................................................................................... N-3
Panavia 2.0 (resin composite) ................................................................................................................................ N-3
A-9

Rely X Ultimate (resin composite) .......................................................................................................................... N-3


Rely X Unicem (resin composite) ........................................................................................................................... N-3
DeTrey Zinc (zinc phosphate) ................................................................................................................................. N-3
Others......................................................................................................................................................................... N-4
Kalzinol (zinc-oxide eugenol) .................................................................................................................................. N-4

Prosthetics
Clinical Stages.............................................................................................................................................................. O-3
History, Examination and Treatment Plan ......................................................................................................... O-3
History .................................................................................................................................................................... O-3
Examination............................................................................................................................................................ O-3
Extra and intra oral ......................................................................................................................................... O-4
Assessment of dentures ................................................................................................................................. O-6
Further investigations..................................................................................................................................... O-8
Diagnoses ............................................................................................................................................................... O-9
Treatment Plan....................................................................................................................................................... O-9
Plaque control ................................................................................................................................................ O-9

The sequence of providing dentures ............................................................................................................. O-11


Preliminary impressions ...................................................................................................................................... O-12
Tray modification ................................................................................................................................................. O-13
Laboratory prescription........................................................................................................................................ O-14

A guide to the choice of special trays ............................................................................................................ O-14


Disinfection and infection control...................................................................................................................... O-15
Partial Denture Design ......................................................................................................................................... O-16
Problem Designs ................................................................................................................................................... O-17
Class IV upper dentures........................................................................................................................................ O-18
Lower free end saddles ........................................................................................................................................ O-19
Design of acrylic partial dentures......................................................................................................................... O-19

Tooth Preparation for partial dentures............................................................................................................. O-20


Selection of abutment teeth ................................................................................................................................ O-20
Rest seat preparation ........................................................................................................................................... O-20
Creation of guide surfaces.................................................................................................................................... O-21
Modifying the survey line..................................................................................................................................... O-22
Modifying tooth shape for minor connectors ...................................................................................................... O-23

Working impressions ............................................................................................................................................ O-24


A-10

Modification of the special trays.......................................................................................................................... O-24


Application of Adhesive........................................................................................................................................ O-26
Taking the impression .......................................................................................................................................... O-26
Lower free-end saddle impressions ..................................................................................................................... O-26
Laboratory prescription........................................................................................................................................ O-27

Trying in the framework ...................................................................................................................................... O-28


Recording the occlusion ....................................................................................................................................... O-29
Wax Try in............................................................................................................................................................... O-32
Fitting the dentures .............................................................................................................................................. O-34
Prosthetic burs ..................................................................................................................................................... O-35

Advice to the patients .......................................................................................................................................... O-36


Review ..................................................................................................................................................................... O-37
Immediate Dentures............................................................................................................................................. O-38
Copy dentures ........................................................................................................................................................ O-39
Introduction ......................................................................................................................................................... O-39
Indications ............................................................................................................................................................ O-39
Procedure ............................................................................................................................................................. O-39

Reline / Rebase ...................................................................................................................................................... O-45


Laboratory reline / rebase.................................................................................................................................... O-45
Chairside reline..................................................................................................................................................... O-47
Soft lining materials.............................................................................................................................................. O-48

Aide Memoirs ............................................................................................................................................................ O-51


Evaluation of the patient and dentures ............................................................................................................... O-51
Primary Impressions ............................................................................................................................................. O-52
Secondary impressions......................................................................................................................................... O-53
Recording the occlusion ....................................................................................................................................... O-54
Wax try in ............................................................................................................................................................. O-56
Fitting the dentures .............................................................................................................................................. O-57
Partial denture design .......................................................................................................................................... O-60

Essential reading .................................................................................................................................................. O-61

Periodontology
Restorative patients and periodontal therapy ................................................................................................ P-2
Periodontal aspects of the restorative History, examination, diagnosis and treatment plan............................. P-2
A-11

History .................................................................................................................................................................... P-2


Examination of new patient ................................................................................................................................... P-3
Diagnosis ................................................................................................................................................................ P-3
Treatment plan ....................................................................................................................................................... P-4
Periodontal indices ........................................................................................................................................ P-5
Basic periodontal examination (BPE) ..................................................................................................................... P-5
Plaque free scores (PFS) ......................................................................................................................................... P-5
Marginal Bleeding free scores (MBFS) ................................................................................................................... P-6
Probing pocket depths (PPD) ................................................................................................................................. P-6
Bleeding on probing (BOP) ..................................................................................................................................... P-6
Mobility .................................................................................................................................................................. P-6
Recession................................................................................................................................................................ P-6
Furcation involvement ........................................................................................................................................... P-7
Suppuration ............................................................................................................................................................ P-7
Periodontal monitoring.................................................................................................................................. P-7
Periodontal recall and maintenance / supportive therapy............................................................................... P-7
Oral hygiene (plaque control) instruction ....................................................................................................... P-8
Tooth brushing instruction ..................................................................................................................................... P-8
Denture hygiene ..................................................................................................................................................... P-8
Smoking cessation counselling ....................................................................................................................... P-8
Scaling........................................................................................................................................................... P-8
Ultrasonic and sonic scaling ................................................................................................................................... P-8
Use of local analgesia in the treatment of periodontal disease ............................................................................ P-8
Use of systemic antibiotics ............................................................................................................................. P-9

Appendix
Internal referral form..................................................................................................................................... Q-2
Student leave of absence form ....................................................................................................................... Q-3
Patient communication form ......................................................................................................................... Q-4
History taking form ........................................................................................................................................ Q-5
Treatment record continuation form .............................................................................................................. Q-6
Plaque free and Marginal bleeding free scores ............................................................................................... Q-7
Diet history sheet .......................................................................................................................................... Q-8
Layout of clinics ............................................................................................................................................. Q-9
Items available from dispensary................................................................................................................... Q-10
A-12

Student summary sheet for preparing unit for use........................................................................................ Q-11


Student summary sheet for cleaning the unit prior to use ............................................................................. Q-12
Needlestick and sharp injuries guidance ....................................................................................................... Q-13
Panavia F 2.0 step-by-step guide .................................................................................................................. Q-15
RelyX Ultimate step-by-step guide ............................................................................................................... Q-23
RelyX Unicem step-by-step guide ................................................................................................................. Q-29

A-13

The Clinics ................................................................................................................................................................. B-2


Equipment .................................................................................................................................................................. B-2
Operators cabinetry................................................................................................................................................... B-3
The dental chair ......................................................................................................................................................... B-5
Chair movement .................................................................................................................................................. B-5
The footswitch ..................................................................................................................................................... B-7
Dental operating light .......................................................................................................................................... B-7
Chair-mounted spittoon / suction unit ................................................................................................................ B-8
Headrest ............................................................................................................................................................ B-10
Operators control module ................................................................................................................................. B-11
Safety notes ....................................................................................................................................................... B-12
Assistants control panel..................................................................................................................................... B-13
3 in 1 syringe ...................................................................................................................................................... B-14
Latex safe areas ................................................................................................................................................. B-14
Student attendance ................................................................................................................................................. B-14
Clinic hours and appointments ............................................................................................................................... B-15
Patient appointment bookings .......................................................................................................................... B-15
Patients failing to keep appointments............................................................................................................... B-15
Treatment of patients.............................................................................................................................................. B-16
Responsibility for patient care ........................................................................................................................... B-16
Transfer of patients ........................................................................................................................................... B-16
Referral of patients ............................................................................................................................................ B-17
Professional conduct and patient management .................................................................................................... B-17
Dress code.......................................................................................................................................................... B-17

B-1

The Clinics
The Clinics are divided into North and South clinics, with staff treatment surgeries in the area between
At the start of each term each member of staff will be allocated a group of students. They will be responsible for
their teaching and assessment for that term. At the end of term they will be asked to provide term grades and
comments on the students performance.
For each session there is a named designated consultant who should be consulted if any difficulties arise. Usually this
member of staff is already teaching in the clinic but on occasions may be treating patients in a side surgery or be
elsewhere in the hospital.

Equipment
There are a total of 62 dental operating cubicles, 26 in the North Dental clinics and 36 in the Conservation clinics on
the South. On the south side there are 10 A/DEC chairs and lights, these can be found close to the windows. The
mains switch for these are on the bracket table (as a small switch just under the right hand side) see below.

Figure B1 - Operator's control module

B-2

The majority of the units are of a PLANMECA type with a side delivery operators control module except for those
with a pillar mounted control module which are adaptable for use by left handed operators.
In addition there are several knee brake chairs for patients who would be otherwise compromised. These can be
identified by senior staff.
Patients may require the use of a HOIST THIS IS LOCATED ON THE SOUTH SIDE, please ask nursing staff for
assistance if the hoist is required. In addition there is one latex safe unit on the North side, chair no 5, and on the
South side, chair No 79. These are situated close to the windows The following notes will be of assistance in
explaining the equipment basic controls and functions.

Figure B2 - knee break chair

Operators Cabinetry
This is located to the left of a patient seated in the dental chair.
The diagram below identifies the facilities. In addition there are
mobile trolleys containing most materials not in the cabinetry.
These are BLUE for Conservation and WHITE for prosthetics.
Support staff may be approached if stocks are low.

Figure B3 Unit Drawers

B-3

Figure B4 Conservation Trolley (Blue)

The mobile cart has its own power supply this must be
connected to the mains and switched on for the silamat to
operate!!

Figure B5 Mobile Cart

B-4

The Dental Chair


The dental chair is centrally located in the cubicle and must not be moved without staff consent. It has two sets of
controls HAND CONTROLS AND FOOT CONTROLS the foot controls to permit chair adjustment during operating
without gloved hands either contaminating or being contaminated by the hand controls. The control functions are
shown below.

Chair Movement
Buttons-Chair up, Chair Down, Backrest up, Backrest Down
Manual Movement (Press & Hold) 4 PRESET POSITIONS A.B.C.D. (QUICK PRESS) A&B LIGHT ON
5TH PRESET IS SPIT POSITION
Safety Switches

SAFETY PLATES AND ARM SWITCHES (HE3)


SPITTOON (HE51)
BACKREST

Figure B6 - chair overview

B-5

NB The arms on the chair may be removed or rotated 90 degrees for access.

B-6

The Footswitch
The switch controls the chair plus the rotary instruments, the diagrams are self explanatory

Figure B7 - footswitch

Dental Operating Light


The standard OPERATING light is ceiling mounted ON A
TRACK and the lenses must be kept clean to maintain
efficiency. It has a sharply delineated cut-off to avoid
dazzling the patient. There are three settings:
1.
2.
3.

When the switch is in the up position at its


brightest
When down to prevent composite material from
premature setting.
When in the middle OFF

The operating controls are illustrated below.

Figure B8 Operating light

B-7

NB On entry and exit from the chair the light should be moved to protect all concerned !!!!!
NB If the green light on the track is not on, the bulb may have gone or the unit is not turned on.

High
Off
Low (composite)

Figure B9 - operating light with switch in full position

Chair-mounted Spittoon/Suction Unit


This is mounted to the patients left when seated
in the dental chair. It offers one touch filling for
plastic disposable cups, and mouth rinsing facilities
for the patient and has a triple function syringe,
high and low volume suction for use by the
chairside assistant. The key features are shown
below.

Figure B10 - Suction unit

B-8

PLEASE!!!!

NO SOLIDS DOWN SPITTOON BOWL PAST BOWL FILTER!!


NO FLUIDS DOWN SPITTOON IF UNIT NOT TURNED ON!!!
B-9

Headrest
For patients in wheelchairs, the headrest can be reversed to assist in supporting the head. It also can be used in this
way for use with smaller / shorter patients in the dental chair.

B-10

Operators Control Module


The operators module and foot control should remain out of the way WHEN NOT IN USE
The module should be positioned for use only when the patient has been seated. The module accommodates FOUR
outlets, a control panel and a work tray of which details are illustrated below. All units have fibre optic lights, the
student should respect the delicate nature of these and should check after removal of the handpieces the tips of the
light source are intact!!!!
B-11

Figure B11 - operators module

The order of the storage area is as above.


NB The F/R symbols on the slow speed motor!

Safety Notes
Chairs have pre programmed positions for reclined operating positions and upright patient entry/exit position.
Movement between these positions can be stopped via the foot switch plus other buttons on the console.
B-12

Great care must be taken not to trap limbs or equipment e.g. operating stools below the chair or the attached
spittoon unit during programmed sequences.
Air scaler tips and burs in handpieces should be placed in the instrument holders on the operators control
module in such a way as to prevent inadvertent injury to the operator or the patient, before leaving the unit e.g.
to fetch a member of staff or further equipment all burs should be completely removed and safely positioned on
the bracket table.

Assistants Control Panel

B-13

3 in 1 Syringe
The outer ring must be retracted to allow the plastic tip to enter and release!!!!

Figure B12 3-in-1 unit

Figure B12 - push outer ring in to insert 3-in-1 tip

Latex Safe Areas


On each clinic there is one unit dedicated to treating patients in a latex safe environment. No one should enter the
unit wearing latex gloves and should wash hands thoroughly before entering.
Latex safe items available include;
Gloves
Rubber dam
Wedgets
Citanest Local Anaesthetic

Please check before removing items from the trolleys or dispensary

Student attendance
Students allocated to the Clinics are required to attend for a full morning or afternoon session even if their patients
have cancelled or fail to attend for their appointments. They should report to the member of teaching staff in
whose group they are allocated for that session and may be asked to undertake duties such as a surgery assistant for
a colleague. In addition they may be asked to deputise for an absent student. If a student is not required to assist in
this manner, time may be used for library study or laboratory work, provided that a member of staff knows where
the student may be contacted.
Any students who are absent should have informed the Learning and Teaching office via their normal route. The staff
member expecting that student should be informed as soon as the absence is noted and arrangements made for
their patients.
B-14

Clinic Hours and Appointments


The Restorative clinics are open from 0900 to 1230 hours and from 1330 to 1645 hours. Students are expected to
have arrived 10 to 15 minutes earlier to carry out the necessary unit preparation procedures and to have collected
any necessary laboratory work and instruments from the dispensary.

PATIENT APPOINTMENT BOOKINGS


In general students will be allocated to a full morning or afternoon session, they have three appointment slots
available to them for each session but will usually merge appointment times to allow for longer procedures to be
carried out, but it is unadvisable to keep a patient for longer than 2 hours.
Appointment times are:
09:15
10:15
11:15

13:45
14:45
15:45

Appointments must all be made on the hospitals patient administration system (PAS) via the receptionists or the
student waiting list co-ordinators. Any student failing to book patients appropriately should be informed of the
correct procedure in the first instance.
Students must not book appointments for sessions on which they are not allocated to the Conservation/Restorative
Clinic, except in special circumstances, eg. if a patient is experiencing post-operative pain. Permission for an extra
session must be obtained from the senior member of staff supervising the clinic on the session concerned.
Appropriate request forms are available from Timetabling team.
Students should ensure that work is completed and a subsequent appointment arranged so that they leave the clinic
no later than 12:30 or 16:45 hours in order that the reception clerks, support workers and dental nurses can
complete their duties at the proper time.
The reception staff have authority to make bookings for any vacant appointments and may use these either for
patients who telephone to report post-operative problems or to request a rearranged appointment.
Students should not telephone patients directly, the receptionists or waiting list coordinators can carry out this
function.
The student should confirm with the Reception Office at least six weeks in advance of absences from allocated
sessions for examinations, elective visits, etc. so that no appointments have been booked.

Patients failing to keep appointments


If a patient fails to keep an appointment their hospital record card should be brought to a member of staff, dated,
marked DNA and initialled. A further appointment, giving the patient reasonable notice and allowing sufficient time
for postal delivery, should be arranged through the Reception Office.
Failure to keep a second consecutive appointment should also be noted in the hospital record card and a standard
letter, obtainable from the Waiting List Coordinators, sent to the patient advising them that unless the Department
hears to the contrary, it will be assumed that arrangements have been made for treatment to be completed
elsewhere.
B-15

If a new patient from the waiting list or a patient sent an appointment for recall inspection fails to attend, the record
card should be marked DNA, but no further appointment need be arranged unless at the patients subsequent
request.

Treatment of Patients
No patient, whether a member of the public or a student, may be treated without being registered by the Dental
Hospital Office and having a record card.
No treatment should be initiated and no patient discharged from the clinic without the approval of a member of
staff.
Patient record cards should be returned to the Reception Office at the end of each appointment and must not be
retained by the student.

Responsibility for Patient Care


The ultimate responsibility for a patients care lies with the supervising tutor. For this reason it is essential that the
supervisor carries out an inspection of the patient before and after treatment.
Students are required to fully see through the completion of the care of a patient and should not cherry pick
treatments that suit themselves best. Treatment can be provided by other students by arrangement, but it is the
duty of the student formulating the treatment plan to ensure that all treatment has been carried out.
Patients attending the hospital are provided with one course of treatment only, and at the end of that course they
are discharged from the hospital.

Transfer of patients
Students must not transfer patients to fellow students without approval from a member of staff.
Transfers are normally permitted only when:
a)

the patient is to be passed from a junior to a senior student for items of advanced work;

or
b)

the patient is no longer able to attend for the sessions on which the student is allocated to
Restorative Dentistry, for example when allocations are changed at the beginning of a new term.

Transfer to another student will also be necessary following the Final Examination when successful candidates will
be expected to arrange for the continuation of treatment for patients requiring further work. You will be advised of
the procedure that will be adopted at the appropriate time.

B-16

Referral of patients
Should letters require to be written to referring practitioners, students are encouraged to draft these themselves.
The supervising member of staff should check the letter and then arrangements made for the departments Medical
Secretary (Melanie Thewlis) to type the final agreed version. The typed letter should be signed by the student and
countersigned by the supervising staff member.

Professional Conduct and Patient Management


Students are expected to comply with all health and safety procedures including cross infection control, behave
appropriately as professionals at all times on the clinic and should not engage in idle chat or gossip with each other
especially in earshot of patients.
All students should have their name badge on at all times and conform to the current dress code.

Dress code
Regulations on Dress and Personal Appearance in the School of Dentistry
and in Outreach Settings

These regulations have been drawn up to promote a clinical, professional appearance anywhere on Level
5 of the Worsley Building, all clinical areas in outreach settings and the clinical skills classrooms.
Clothing and personal appearance must accord with the reasonable expectations of a member of the public
for a professional person and all students must pay the utmost attention to tidiness, cleanliness and
hygiene. The regulations cannot be exhaustive in content and supplement the requirements of any
individual employee or student in NHS premises. The policy is based on the LTHT Trust Dress Policy which
is available at http://www.dentistry.leeds.ac.uk/documents/dresspolicy2012.pdf.

From 7 May 2013 scrub suits must be worn by all students in clinical settings, including the clinical
skills classrooms. Staff will make spot checks at the beginning of sessions and students will be required
to leave clinics if they are not wearing scrub suits or are otherwise unsuitably attired. Decisions will be
made at the discretion of clinical staff or qualified dental nurses, are not open to negotiation and must be
met with a mannered response.

Please note that scrub suits can be worn in the Trust, anywhere in the LDI and on level 7 of Worsley
Building (including the caf). Scrub suits must not be worn outside of these areas and this includes
travelling to and from the LDI and Outreach settings.

Personal Protective Equipment (PPE) should be worn only in clinical or clinically-related areas and clinical
skills classrooms. They must be removed before leaving the area and discarded only in the bins provided.
Under no circumstances should PPE be discarded in locker rooms or in any other area of the School of
Dentistry. PPE must not be worn in any location outside of clinical areas or clinical skills rooms (this
includes eye protection).
B-17

It is recommended that students keep a spare set of scrub suits in their lockers in case of accidents, loss or
damage. Please note that the LDI does not keep spare sets of scrubs for student use.

Do Wear:

University issued scrub suits.


Clean shoes which should be soft-soled, low heeled with enclosed toes and heels.
Clean hair of moderate style and colour (extremes of changing fashion are not allowed).
Long hair tied back and off the collar (which includes the need for draping headwear worn for
religious reasons to be tied back or with the length enclosed within the gown. The wearer must
possess a sufficient number of headdresses to wear a freshly laundered one each day).
Short, clean and neat fingernails
A sticky label with your name on (the labels will be provided at clinic receptions). Due to infection
control issues name badges should no longer be worn.

Do *NOT* Wear:

Wrist watches, bracelets or bangles (except for those bracelet symbols worn for religious
reasons, which must be either removed or pushed up the arm and secured in place with tape). The
security of jewellery that a student or member of staff has been asked to remove remains the
responsibility of the wearer.
Facial, hand or other jewellery (except one stud per ear or a wedding ring)
Tongue, facial or other visible studs
Nail extensions or varnish
Strong odours, perfume or aftershave
Facial stubble
Wherever possible tattoos should be covered
Open backed or open toed footwear, crocs, trainers, ballet-type slippers or other similar
footwear.

All staff must be bare below the elbows when working in or entering clinical environments to facilitate
effective hand hygiene. For the purposes of this policy this means that sleeves must be either rolled up or
of a length that leaves the forearms completely uncovered, no wrist watch or any other wrist coverings are
worn and no jewellery is worn below elbow level other than a single plain wedding band.

Failure to comply with these Regulations (which is a mandatory LDI policy) is an offence under the
terms of the General University Disciplinary Regulations and/or the Unsatisfactory Students
Procedure and will be reported to the University where further action will be taken.

Laundering of Scrub Suits


B-18

Scrub suits must be changed whenever soiled and at least daily.


The Trust laundry service is not available for non Trust issued scrub suites therefore scrub suits must
be laundered at home in accordance with the guidance detailed below or in accordance with the
temperature stated on the garment care label (60 degrees). They must be transported to and from work
in a clean plastic bag.
Where items are laundered at home they must be washed at the hottest temperature for the fabric.
Domestic washing machines only achieve social cleanliness and are rarely capable of achieving
thermal disinfection. It is important that clothing of clinical staff is washed appropriately in order to
achieve thermal disinfection. They must be washed on a machine cycle that maintains a temperature of
60C for at least 10 minutes.
Scrub suits must be washed separately from other items to avoid cross contamination. Tumble drying
will help to reduce the risk of microbial survival.
When dry, they need to be ironed with a hot iron paying particular attention to the seams as this is
where bacteria may harbour.
Staff wearing head covering for religious reasons must ensure that they have sufficient to wear one that
is freshly laundered each day.

Replacement scrub suits

Four scrub suits per student are provided to students at the start of their programme of study and they
should last for the duration of the programme.
It is the students responsibility to look after their scrub suits over the duration of the programme. If
scrub suits are lost or damaged through negligence then they must be replaced at the students own
cost.
In this situation replacement scrub suits should be ordered directly from E&E Workwear via a link which
will be made available separately.
If a student requires a replacement scrub suit for health reasons or through damage that is not their
fault then they should request this through the Student Education Office.
If there are any issues relating to payment for replacement scrub suits they will be referred to the
School Education Service Manager.

B-19

General Clinical Working Practices................................................................................................................ C-2


Infection prevention and control .............................................................................................................................. C-2
Standard precautions .......................................................................................................................................... C-2
Hand hygiene ....................................................................................................................................................... C-2
Personal protective equipment (PPE).................................................................................................................. C-2
Safe sharps management and inoculation injury awareness .............................................................................. C-3
Waste disposal ..................................................................................................................................................... C-4
Containers ............................................................................................................................................................ C-4
Disinfection and cleaning of body fluid spillages................................................................................................. C-5
Hazardous spillages ............................................................................................................................................. C-6
Cleaning dental unit prior to use............................................................................................................................... C-6
Student summary sheet for cleaning unit prior to use ............................................................................................ C-6
Student summary sheet for preparing unit for use .................................................................................................. C-8
Asepsis........................................................................................................................................................................ C-9
Personal illness .......................................................................................................................................................... C-9
Equipment failure / breakdown ................................................................................................................................ C-9
Accidents and emergencies ..................................................................................................................................... C-10
Fire ..................................................................................................................................................................... C-10
Sudden collapse of an individual ....................................................................................................................... C-10
Medical emergencies training for the dental team ................................................................................................ C-11
Medical emergencies drugs and equipment ..................................................................................................... C-11
Medical emergencies audit................................................................................................................................ C-11
Medical emergencies training ........................................................................................................................... C-11
Reporting of incidents ............................................................................................................................................. C-12
Dispensary facilities ................................................................................................................................................. C-12
Cleansing and return of used instruments ........................................................................................................ C-12
Protocols for using instrument kits in all clinical departments ............................................................................. C-13
The role of the dental nurse .................................................................................................................................... C-14
Transport patients ................................................................................................................................................... C-14
Hospital laboratory .................................................................................................................................................. C-15
Endodontic x-Ray facility ......................................................................................................................................... C-16
Prescriptions ............................................................................................................................................................ C-17

C-1

General Clinical Working Practices


While operating, staff and students should be conscious of the importance of Infection Prevention and Control
practices, asepsis, cleanliness and sterility. You should avoid putting your hands through your pockets or your hair.
You should familiarise yourself with the LTHT Health and Safety guidelines.
If you drop instruments on the floor they should be returned to the dispensary and a replacement kit opened. Each
instrument pack has an individual bar-coded label for tracking purposes, the label should be placed in the patients
notes DO NOT stick these labels around the unit, they are difficult to remove.

Infection prevention and control


The LTHT Infection Prevention and Control Policies are available on the Trust Intranet and externally
at http://www.leedsth.nhs.uk/sites/infection_control/

Standard precautions
Is a system of precautions to be used with everybody which protect patients, staff and visitors and assumes all body
fluids are potentially infected.
They include the following:

Hand hygiene.
Correct use of personal protective equipment (PPE).
Safe sharps management.
Safe disposal of waste and linen.
Disinfection and cleaning of body fluid spillages.
Care of your broken skin.

Please see LTHT Standard Infection Prevention and Control Precautions Policy for more information.

Hand hygiene
Clean your hands before and after each patient contact, before performing an aseptic task, after contact with blood
and body fluid, after contact with the patients surroundings and after removing gloves. Use the correct technique:
wet your hands, apply soap and use 5 strokes per movement when washing hands and at least one stroke per
movement when using alcohol gel. Copies of the correct technique are displayed within the clinical area.
Hand Hygiene opportunity and technique audits are undertaken in the clinical areas to provide assurance of
compliance.
Please see LTHT Hand Hygiene in Practice Policy for more information.

Personal protective equipment (PPE)


Protective clothing
Staff and students should wear protective clothing e.g. clinical gown, plastic apron or surgical gown whilst treating a
patient or working in the Optec laboratory to protect their clothing from splash, spatter and dental products.

C-2

Eye protection
Safety spectacles are available and should ALWAYS be provided for, and worn by, patients in the supine position in
the dental chair. After use, safety spectacles must be returned to the dispensaries for cleaning, drying and re-issue.
Safety visors must be worn during all operative procedures. Operators and chairside assistants MUST wear Safety
visors when operating with Ultrasonic/Sonic Air Scalers or Rotary Cutting Instruments. Wearers of prescription or
plain glass spectacles are recommended to consider obtaining prescription impact resistant/shatterproof safety
spectacles.

Gloves
Single use gloves should be worn for all procedures and changed between patients. Care should be taken whilst
wearing gloves; you should be conscious of where your hands are and avoid contaminating patient notes or pens, for
example, by touching objects outside the operating zone.
Gloves are highly flammable. Keep gloved hands clear of Bunsen burners or other naked flames. Before using a
Bunsen burner or naked flame in the clinical area fill the product sink with cold water, this is to submerge the gloved
hands if an incident should occur
Gloves should not be worn outside the clinical area

Masks
Single use face masks must be worn during all operative procedures. Wearing a face mask whilst treating a patient
reduces the risk of the operator and assistant inhaling aerosols which are potentially contaminated with bacteria,
saliva, blood, tooth and restorative material debris, particularly when Ultrasonic/sonic/air scalers or high speed
rotary cutting instruments are in use.

Safe sharps management and inoculation injury awareness


You should read the LTHT Needlestick Prevention and Actions to be taken after Exposure to Blood and Body Fluids
(including HIV Post-Exposure Prophylaxis) Policy and be aware of the importance of protecting yourself from a
sharps injury.
If you sustain a sharps injury i.e. stabbed with sharp instrument, needle, blade or piece of glass or an unknown sharp
object protruding from a waste receptacle you should do the following:
1. First aid - bleed it, wash under running water and cover with a water proof dressing
2. Report to senior person and follow the LTHT Needlestick Prevention and Actions to be taken after Exposure
to Blood and Body Fluids (including HIV Post-Exposure Prophylaxis) Policy

Handling of 'sharps'
Sharps include dental instruments, scalpel blades, hypodermic needles or items of equipment which have sharp
pointed tips e.g. dental burs and scaler tips.
Viral diseases such as HIV and Hepatitis B and C can be transmitted by injury with sharps contaminated with
infected blood products, therefore great care should be taken when handling or disposing of sharp items.
Local analgesia is administered using the Ultra Safety Plus System which has a protective sheath and handle,
following initial use the needle should not be left exposed, the protective sheath should be placed in the holding
position (single click) and when finished the sheath should be locked (double click) before disposal.
C-3

Air scaler tips and burs in handpieces should be placed in the instrument holders on the operators control module in
such a manner as to prevent inadvertent injury to operator or the patient when operating or when entering or
leaving the dental cubicle.

Re-usable 'sharps'
Instruments and handpieces are reusable items, as are some other items of kit e.g. scaler tips, selected burrs and
cartridge syringes (excluding cartridge and needle). These should be returned to the dirty dispensary and placed
into the correct boxes for re-processing.

Waste disposal
Disposal of 'sharps'
Single Use Sharps
Needles, glass breakable items, e.g. local anaesthetic cartridges (excluding the syringe), matrix strips, any

instruments marked
patient use.

and scalpels are single use items they cannot be re-used and must be disposed of after each

When finished with, these items must be discarded immediately into the rigid yellow plastic purple lidded sharps
containers available in each dental cubicle.
DO NOT over fill the sharps containers the full line is marked at of the container; please inform a nurse when the
container is full and it will be changed.
NEVER insert hands into sharps disposal containers in an attempt to recover misplaced items.
UNDER NO CIRCUMSTANCES MUST SHARPS BE DISPOSED OF INTO UNDER-SINK WASTE.

Containers
Disposal of Clinical Waste in the Dental Institute
The way waste is disposed of in the Dental Institute is different to general practice and in Out Reach clinics. A wide
range of both hazardous and non hazardous waste is produced in the Dental Institute, to prevent putting hazardous
waste into the wrong waste stream it was agreed that the Dental Institute staff/students would place all clinical
waste contaminated with dental materials and pharmaceutical waste (all products used in the mouth), including
gloves into yellow bags, Sharps into purple lidded sharps bins and general waste, which includes paper towels and
clean instrument packaging into black bags.
Foot operated waste bins are provided in the clinical area:
Yellow with a yellow clinical waste bag.
White with a black general waste bag.
Please see the Safe Disposal of Dental Clinical Waste poster below.
Sharp items must not be placed into the plastic bags in these bins. Careless disposal of any sharp item into these
bins risks serious injury to operator and assistant but particularly to the domestic staff who remove the plastic bin
liners.
Note: - Under no circumstances should any clinical material/instruments be removed from the unit and placed in
the pockets of the clinical gown. This practice is extremely dangerous.
C-4

Figure C1 - Safe disposal of clinical waste.

Disinfection and cleaning of body fluid spillages


Avoid body fluid spillages if possible, if a spillage occurs e.g. blood, vomit etc, it must be dealt with immediately, the
affected area should be cleaned and disinfected with a product which gives you 10.000 ppm of available chlorine;
use the spillage kit located on clinic (See picture below) and ask for help from either your supervisor or a dental
nurse.

Figure C2 - Hazardous fluids spillage kit.

C-5

Hazardous spillages
All spillages of toxic/inflammable materials e.g. mercury, acrylic monomer, ethyl chloride etc MUST be immediately
reported to the senior member of staff and senior dental nurse on duty and appropriate steps taken to prevent
injury to patients, undergraduates and staff.

Cleaning dental unit prior to use


The dental unit requires cleaning prior to use, between each patient and at the end of the session,

Student summary sheet for cleaning unit prior to use:


You will find on the bracket table in each cubicle a blue micro fibre cleaning cloth to be used for the first
clean of the day. Each cloth is used only in one cubicle and then discarded. You should always wear
appropriate personal protective equipment when preparing your unit for use

To use:
Wet the cloth in the product sink (do not use the hand wash basin), squeeze out excess water, fold into half
and then half again.
The cloth should always be dampened for use. As each side is soiled the cloth should be turned to a clean
side until all 4 quarters have been used. The cloth can be rinsed again and can continue to be used until all
the surfaces of the unit have been cleaned.
Remove foot control from storage location

The unit should be cleaned in the following order:


1.

All worktop surfaces and ledges (move all equipment stored on worktop e.g. sharps bin, etc - all items should
also be externally cleaned)

2.

Bracket table including all exposed surfaces of delivery arm, control panel, handpiece and 3 in 1 tubings,
operating light and light track arm,

3.

Mobile nurses cart all external surfaces including plug cable and ledges, internal pull out shelf
(Amalgamator equipment)

4.

Patient chair, escort chair, operator chair, assisting chair all surface (including back supports and wheels)

5.

All other exposed surfaces of the unit includes sides of spittoon and suction unit, base plate

6.

Spittoon and cup filler, foot control

After each patient you should clean the unit using a Saniwipe cloth ( refer to summary sheet for flushing
waterlines)
If you require any assistance or advice please ask a dental nurse or clinical support staff
C-6

Flushing of dental unit water lines (DUWL)


To reduce the risk of infection to patients and staff/students The Department of Health (HTM 01-05) recommends
flushing untreated DUWL at the beginning and end of the day for at least two minutes and after any significant
period when they have not been used e.g. after lunch breaks. In addition, they should be flushed for at least 20 - 30
seconds between patients and when monitoring is undertaken the TVC should be expected to lie in the range of 100
-200colony forming units per millilitre (cfu/ml).
The agreed DUWL standards for the Leeds Dental Institute, Seacroft Orthodontic Unit and Westmoreland Unit are
<100 cfu/ml.
The DUWL in the Dental Institute are treated with two chemical biocide products

BRS Forte - removes existing biofilms


Alpron - A continuous dosing system of a 1% solution that aims to maintain the microbial count at the
acceptable level of <100cfu/ml.
The DUWLs should be flushed for 30 seconds at the beginning and the end of the day and if used for treatment for
30 seconds between patients
Please see the Decontamination and flushing of Dental Unit Water Lines in LTHT protocol (LTHT Infection
Prevention and Control Policies) and Student summary sheet for preparing unit for use.

C-7

Student summary sheet for preparing unit for use:


MORNING (or 1st use of day)
SWITCH ON POWER (if necessary) Dental nurses or support staff will have already cleaned the spittoon
inserts and filters. 1 litre of water will also have been rinsed through the suction tubes please check if
you are unsure this has been completed

FLUSHING INSTRUMENT DELIVERY WATERLINES:


(Short Flush) You should always wear appropriate personal protective equipment when preparing
your unit for use
1

Press programme key D to lower chair (if necessary)


Move spittoon to right to allow view of flush holder cover

Remove cover and insert high speed and slow speed waterlines into two of the larger holders
(do not use the small holders at rear of holder)

Press programme key (bottom left on key pad) for approx 3 seconds (until signal bleep heard).
Flushing will begin (the display panel will indicate time count down). At the same time hold both 3
in 1 syringes over the spittoon and manually flush for 30 seconds.
(When flush cycle is complete HE36 will appear in display panel)

Return all waterlines into correct position on bracket table replace flush holder cover and return
spittoon into position

PLEASE ASK A QUALIFIED DENTAL NURSE FOR ASSISTANCE IF YOU ARE UNSURE OF ANY PART OF THE
PROCEDURES

AFTER EACH PATIENT


1
Between all patients aspirate 1 disposable cup of water through both suction hoses and clean
spittoon with SANIWIPE cloth check underneath of spittoon bowl in case of spillage (wipe if necessary)
2

Perform short flush procedure as described above

3
Clean all surfaces, bracket table, patient chair, operating light (check it is cool), handpiece and 3
in 1 tubing with SANIWIPE cloth( check cleaning protocol if unsure)
END OF DAY CLEANING PROCEDURES ARE USUALLY COMPLETED BY DENTAL NURSES OR CLINICAL
SUPPORT STAFF

C-8

Asepsis
All staff are required to complete an Asepsis competency assessment before undertaking any Aseptic procedure e.g.
cannulation and accessing intravenous lines.

Personal illness
Do not come to work if you experience symptoms of viral gastroenteritis (diarrhoea, and or vomiting), influenza or
think you may have any other infectious disease e.g. mumps, chicken pox and measles. Staff members should inform
their line manager and students should report to the administration office via the portal in the usual way.

Equipment failure / breakdown


Equipment failures / breakdowns must be reported immediately to the Senior Dental Nurse on duty who will make
the necessary arrangements for repairs to be undertaken and will reallocate the operator to an alternative dental
cubicle if possible. In the event of electrical malfunction, immediately turn the main isolation switch (see below) to
the OFF position.

C-9

Accidents and emergencies


It is the responsibility of all staff/undergraduates to familiarise themselves with the location of emergency exits and
exit routes/fire alarms/emergency telephone/fire fighting equipment and the resuscitation trolley. Fire drills will be
held when appropriate.

Fire
If the fire alarm sounds proceed with your patient without delay in an orderly manner to the nearest marked fire exit
and thence out of the building. If you discover a fire activate the nearest alarm without delay and follow the above
instructions. Do not delay to collect personal items.

Sudden collapse of an individual


All undergraduates and staff should ensure that they are competent in basic life support techniques. These skills
must be updated regularly. The Dental Institute now has a designated facility for updating staff and students in life
support. In the event of any individual collapsing suddenly, call immediately for assistance and, if necessary,
immediately commence basic life support procedures to maintain Airway, Breathing and Circulation. It is the
responsibility of all staff and students to know the site of the emergency equipment and be able to summon help
immediately the Emergency Number to call is 999
There are fully equipped resuscitation units plus mobile oxygen supplies in the North and South Clinics. Students
must be aware of the position of these units and how to turn on the oxygen.!!!!!

Figure C3 - Emergency trolley.

C-10

Medical emergencies training for the dental team


Medical Emergencies in the dental setting are rare, but may occur at any time and involve a patient, visitor or
member of staff. Members of the dental team need to be prepared for these and familiar with the procedures in
place in Leeds Dental Institute.

Medical emergencies drugs and equipment


Medical Emergency bags, associated oxygen and equipment plus an aide memoire manual are located on yellow
crash trollies in several locations in the level 5 clinics. Identify the nearest trolley to where you are working and
familiarise yourself with it.

Figure C5 - Medical emergencies.

Figure C4 - Contents of emergency bag.

Medical emergencies audit


Each time an acutely unwell patient is managed in Leeds Dental Institute clinical areas an audit form should be
completed and submitted. These are included in the Medical Emergency bags.

Medical emergencies training


Medical Emergency Training for the Dental Team in Leeds Dental Institute is given by Mike Lowry
(m.lowry@leeds.ac.uk) and Anthony Hoswell (A.D.Hoswell@leeds.ac.uk). Both have extensive experience
of managing acutely unwell patients and training members of the dental team. They are based in the Medical
Emergencies Simulation Suite (room 6.071), which is between the Dean/Directors office and the level 6computer
cluster.
The training offered includes simulation of acutely unwell patients using a sophisticated manikin in a safe
environment where it doesnt matter if errors are made. Video recordings of the simulation personal to those in
the training session are reviewed to highlight good practice and where there are professional development needs.
Students will receive training as part of the course, staff members should contact Mike or Anthony or visit them in
the room to arrange a training session.

C-11

Reporting of incidents
All accidents, however minor they might appear, involving staff, undergraduates or patients MUST be recorded in
the appropriate incident book obtainable from the Senior Nurses on the department and must be countersigned by
the senior member of staff on duty. In the event of needle stick type follow the LTHT Needlestick Prevention and
Actions to be taken after Exposure to Blood and Body Fluids (including HIV Post-Exposure Prophylaxis) Policy.
Students must be familiar with the steps to be taken when a patient collapses and in such an event put the necessary
measures into action calmly.

Dispensary facilities
There are two dispensaries, one in the North and one in the South clinics. These are staffed by support workers who
issue sterilised equipment (handpieces, examination and conservation kits, cartridge syringes, burs etc) and a range
of sundry/replacement items not stocked in the individual dental cubicles. The dispensary has two separate counter
areas the Sterilised Instrument Collection area for the collection of pre-sterilised equipment, instruments etc and
the Instrument Return area for returning used instruments/kits to avoid cross infection. Replacements for faulty,
damaged or broken equipment / burs / instruments etc may be obtained from the dispensary on returning the item
concerned. Equipment/burs which have not been pre-sterilised MUST NOT be brought into the clinic or used in the
treatment of patients. The students should also be aware of the clinical trolleys BLUE & WHITE which are also restocked via support staff.
Collection and handling of pre-sterilised instruments
Certain items of equipment (handpieces, kits etc) must be signed for on collection and return. Pre-packed kits and
instruments must not be unwrapped until the patient arrives and is in the dental chair. Instrument kits should be
checked and the checklist ticked that the kit is complete before using - see appendix Protocols for using
instrument kits in all clinical departments.

Cleansing and return of used instruments


Undergraduates are responsible for the initial
cleansing, collation (and reracking/repackaging where
appropriate) and safe return of
handpieces/kits/instruments/mixing slabs etc which
obtain from the dispensary. The bar code system must
followed. Returned instruments must have the check
properly filled in and arranged so that the check sheet
clearly seen.

they
be
sheets
can be

Figure C6 - Correct layout of returned instruments.

C-12

IMPORTANT NOTICE TO ALL STUDENTS


PROTOCOLS FOR USING INSTRUMENT KITS IN ALL
CLINICAL DEPARTMENTS

DO NOT OPEN ANY PACKS UNTIL THE PATIENT HAS ARRIVED.

EACH PACK HAS AN INDIVIDUAL BAR-CODED LABEL FOR INSTRUMENT


TRACKING. THERE WILL BE A PEEL OFF LABEL ON THE OUTER PACKAGE ONE
SMALL LABEL SHOULD BE PLACED AGAINST CURRENT ENTRY ON PATIENT NOTES

INSIDE ALL KITS / INSTRUMENT TRAYS THERE WILL BE A PAPER TICK BOX CHECK
SHEET YOU MUST TICK EACH BOX ON THE SHEET TO CONFIRM THAT THE KIT
/TRAY HAS THE CORRECT INSTRUMENTS. THIS LIST MUST BE RETAINED
IF THERE IS A MISSING INSTRUMENT PLEASE NOTIFY THE SENIOR DENTAL
NURSE or DENTAL SUPPORT STAFF IMMEDIATELY.
AT THE END OF THE PROCEDURE EACH BOX ON THE CHECK SHEET MUST BE
TICKED AGAIN TO CONFIRM THAT THE CORRECT INSTRUMENTS ARE BEING
RETURNED. THE CHECK SHEET SHOULD ALSO BE SIGNED AND NAME PRINTED
IN THE BOX MARKED SCRUB NURSE YOU SHOULD ALSO STATE THE
DEPARTMENT. THE CHECK SHEET MUST BE PLACED BACK INSIDE THE KIT/TRAY
AND RETURNED TO THE DIRTY AREA.
If kits / trays are returned to BBraun incorrectly (i.e. without check sheets or
with missing instruments), a non conformance report will be sent to the
Dental Nurse Manager. This will instigate an investigation by the senior dental
nurse to establish why it has been returned incorrectly.

SINGLE PACKAGED ITEMS (Supplementary items) e.g. amalgam gun, syringe will
also have peel off labels on outer package- at the moment there is no need to
place small label on patient notes. Used instruments should be returned to dirty
area / dispensary and placed in the WIRE BASKET in the correctly DESIGNATED
BOX
HANDPIECES will follow procedure as above and be placed in a separate
DESIGNATED COLLECTION BOX
PLEASE ASK A QUALIFIED DENTAL NURSE OR THE DISPENSARY STAFF FOR ADVICE IF
YOU ARE UNSURE OF ANY PART OF THE CORRECT PROCEDURE

C-13

Figure C7 Dental Nurse.

The role of the dental nurse


Dental nurses are valuable members of the dental team. The Senior Dental Nurse and a number of qualified and
student dental nurses, staff the clinics and are available to assist staff and undergraduates at the chairside.
However, there are inadequate numbers of dental nurses to permit all undergraduates to have a chairside assistant
at all times. The supervising member of staff should try to establish if any students require the assistance of a
qualified nurse at the start of a session and the senior nurse for the clinic informed, she will then be able to allocate
resources fairly.
Undergraduates are encouraged not to be selfish in requesting dental nurse assistance and to assist their colleagues
when time permits or when timetabled to do so.

Transport patients
Some of our patients require hospital transport to be arranged for their appointments. The supervising member of
staff will be informed that a transport patient is being treated and should expedite finishing of treatment when the
patient is due to be collected. If the collection is late it is the duty of the student and supervising member of staff to
wait until the transport arrives.

C-14

Hospital laboratory
The in-house production laboratory is where all of our lab work is carried out, a small number of items such as
Procera crowns may be externally sourced. The laboratory receptionist is available during normal clinic hours to
accept and deliver items of lab work.

Figure C9 The laboratory reception.

Students are expected to have a copy of the Dental Laboratory


Services Handbook, this is available from the Laboratory Reception.
In order that the Dental Laboratory will have time to cast
impressions before the end of the morning or afternoon session,
Figure C8 - The Dental Laboratory Services Handbook.
students must not prepare to take impressions for inlays, crowns
and bridges after 1145 hours and 1615 hours. Dental Nurses are
instructed not to dispense synthetic rubber materials after these times.
In order to minimise risks of cross infection all impressions should be washed to remove traces of blood and placed
in the hypochlorite disinfection (PERFORM) for ten minutes before being sent to the laboratory. The laboratory will
not accept obviously contaminated material. Students are also reminded of the need to allow sufficient time to
prepare and cement satisfactory temporary restorations that will protect the prepared tooth without damaging the
gingivae or interfering with the occlusion. The paperwork for prescriptions to the production laboratories is
situated in racks AT VARIOUS SITES ON THE CLINICS. In addition the forms for placing patients on appropriate waiting
lists and/or photography requests/additional X ray requests is in the same location.
The laboratory has a finite amount of storage space. When returning work boxes to the laboratory it must be
clearly stated what needs to be retained and what should be disposed of. The students must make this decision in
conjunction with their supervisor. For Finals cases study models may be retained for a short period of time,
however the working models once finished with may be given to the patient or should be disposed of. They may be
photographed if necessary for a case report.
Any unfitted appliances (due to repeated failure of the patient to return or poor fit and remake required) must be
returned to the lab. There will be consequences for not doing so.
C-15

Endodontic x-ray facility


There are two facilities one in North and one in South, they are not designed for routine/pre-treatment radiographs,
which should be taken in the Radiology Dept but is intended to enable staff/undergraduates to take appropriate
intra oral radiographs during endodontic treatment or other procedures during which it is not appropriate for the
patient to be taken to the Radiology Dept. SAFETY IN THE USE OF X-RAY EQUIPMENT IS OF PARAMOUNT
IMPORTANCE. The rules and safety regulations applicable to this facility are identical to those applicable in the main
Radiology Dept. Undergraduates who have not attended and completed the appropriate approved course of
instruction in radiography are not permitted to take radiographs. Dental nurses are not permitted to take
radiographs.

Radiographs may only be taken with prior


written staff authority and with direct staff
supervision where appropriate. The
operator must stand behind the screen
wall before X-Ray exposure is undertaken.
Students should be familiar with the
control switch and ask for advice as to the
correct settings. The control switch should
be wiped with an alcohol wipe before and
after each patient.
All endodontic radiographs should be
prescribed in the same way as radiographs
requested from the radiography
department, the back of the patient notes
must have an entry for each radiograph
taken, signed by the supervising member
of staff.

Figure C10 The X-Ray control switch

C-16

Figure C11 - X RAY FACILITY NORTH SIDE

Prescriptions
All medications provided by the Institute will require staff authorisation and the prescription should be entered in
the Hospital Records and countered signed. A prescription form will also need to be completed. A Dental Nurse will
provide the medication and arrange for it to be administered. Medications for home use are obtained from the
hospital pharmacy and the patient will be expected to pay the usual prescription charge.

C-17

Student supervision ....................................................................................................................................... D-1


Briefing / debriefing ............................................................................................................................................... D-1
Student assessment ................................................................................................................................................ D-2
Log books .......................................................................................................................................................... D-2
Cause for concern ................................................................................................................................................... D-5
Sessional grade ................................................................................................................................................. D-5
End of Term Reviews .............................................................................................................................................. D-7
How Our Undergraduates Are Taught ................................................................................................................... D-7
Clinical Allocations .................................................................................................................................................. D-9
Examinations in Restorative Dentistry ................................................................................................................ D-10

Student supervision
A good relationship between student and supervisor can be extremely rewarding. Students rely on their tutor to help
turn theory to practice, to give helpful tips and to help reduce anxiety about the procedures they are carrying out.
Tutors have a duty to give good advice, be fair and encouraging, to educate and inform and to help when the time
comes. It is also their responsibility to protect patients and so must be aware of the students limitations and abilities,
oversee all treatment and double check all treatment provided including advice and consent procedures.
In general, when learning a new procedure, students should be shown what to do then do it for themselves rather
than have somebody do the treatment for them (though for reasons of time and demanding clinical situations this
may be necessary).
A good tutor will:

Be proactive, look around and offer tips for better practice.


Demonstrate procedures if necessary but try to avoid taking over unless time is crucial.
Try to give equal time to each student.
Be positive in their appraisal of the students work.
Remember that it is not just a treatment clinic but a teaching hospital, question, viva, set tasks to learn.

Briefing / debriefing
At both morning and afternoon clinical sessions time should be set aside prior to treating the patients for a briefing
session. This takes the form of a tutorial and is designed to discuss the treatments to be carried out during the
clinical session. Nurses allocated to that area should be invited to these briefing sessions so that targeting of
assistance can be made on the basis of need. The briefing sessions are an opportunity to discuss clinical techniques
and procedures, and any uncertainties the students have can be discussed prior to patient contact and the group can
learn as a whole. It is also useful to debrief at the end of the session if time allows.

D-1

Student assessment
The students are assessed in a variety of ways. They are given grades per session, per item of treatment and a
summary grade per term. They also have clinical examinations, some of which will take place during normal clinic
sessions. Not all members of staff are involved in assessment, however they should be aware of the various
examinations and standards expected in order to give formative feedback.

Log books
From January 2008 we introduced a new assessment method in an attempt to improve the standard of clinical
assessment in terms of formative feedback for the students, improved monitoring of progress and a higher degree of
recording of both quality and quantity of work carried out during their undergraduate course. The assessment will
form a clinical log book which will be built upon during the first five years of professional education.
Each item of work carried out, from history and examination to bridges and dentures is assessed by predetermined
criteria and recorded using a simple grading and scoring sheet that will be available on the clinics.
The sheet contains main headings that should be assessed during each procedure as well as an overall score area
that will form part of the Institutes permanent record of a students progress. The sheet itself will remain with the
student as an opportunity to reflect upon past procedures carried out.

The role of the tutor


It is the tutors role to fill in the assessment sheet as any clinical procedure progresses.

D-2

Sign each section, and again at the bottom which is the tutors confirmation that the grades given are an accurate
reflection upon the work carried out
Make any valid comments regarding the part of the procedure so far carried out, particularly if there is an aspect of
learning that has been given
The scoring system has been considerably simplified. There are 3 basic scores that can be awarded.
SI (Satisfactory Independent) Indicates that the part of the procedure has been satisfactorily carried out and that no
help in reaching a satisfactory standard was required of the tutor
SA (Satisfactory Assisted) Indicates again that a satisfactory standard of treatment has been carried out, but with
some essential help from the tutor to make it so. This includes a necessary revision of treatment.
U (Unsatisfactory) The treatment undertaken was of an unsatisfactory standard, compared to what should be
expected of a student at that particular stage in their education

After signing the bottom of a completed sheet, the tutor must then fill in the orange box
on the header. Here, the tutor must give an assessment of the difficulty rating of the
procedure. In loose terms, this translates to;
Difficulty level

Expectation

Uncomplicated simple procedure. No major difficulties anticipated. Should be able to be


carried out by a junior student with assistance but a senior student with more
independence

Routine treatment but with factors making it more difficult such as careful patient
management required or complicating medical history

Treatment items that are more complex than 1 or 2 or outside the scope of training for
the undergraduate curriculum, that may be above that expected of a graduating student
to manage safely without assistance, therefore assistance would normally be expected

D-3

Figure D1 - The Log book.

The Clinical Log Book is a vital part of the Student Record while on the clinics. This document will be audited on a
regular basis and must be kept up to date.
Retrospective completion is not recommended. The completed sheets will go towards the students overall
experience profile and as such will play a part in consideration of that student for inclusion to the GDC register. The
responsibility is on the students not to lose pages or the document. They are kept in a secure area on the clinic.
The responsibility is on the student to acquire the signatures from their tutors at THE time with all comments and
grades etc.
Replacement pages are available on the clinic.
Log books will contain patient information and as such should not leave level 5 once they have started being used.
They should not be kept in student lockers or taken home.
The sheets in the log book indicate which parts of the procedure should be shown to the supervising tutor prior and
receiving a signature prior to proceeding with the next stage of the treatment.

D-4

Figure D2 - Log book inside.

Cause for concern


Any student that is causing concern in terms of professionalism or patient safety should be referred to the clinical
progress committee. Often times these are simple matters that can be rectified, but in serious instances the student
may be suspended from clinical activity. It is however our aim to offer as much support as we can to students who
for whatever reason are struggling to maintain standards and removal from clinics will be reserved for the most
severe cases. A support system is in place and can be brought into action if problems are highlighted.

Sessional grade
In addition to a grade for each item of work which is a measure of how much independence was shown, we also
grade students knowledge, skills and professionalism on an A to F basis according to the table shown below. Grades
A to C indicate students working at or above the level expected for their stage in the course.
A D grade indicates knowledge, skills or attitude that are below the expected level and whilst still indicative of a
bare pass, should be seen by the student as an indication that improvement is required.

D-5

D-6

End of term reviews


At the end of each term each group of students will be timetabled for a review meeting, usually with their tutor
throughout the term, but sometime if that tutor is unavailable another tutor will be timetabled. This session is an
opportunity to reflect upon the progress made that term.
The session requires the student to fill in a proforma listing their perceived strengths and weaknesses, this is used as
the basis for the discussion. The session is to be a positive process looking at areas for improvement and discussing
how these may be achieved. The totals figures are for guidance only and to give the student an idea of where they lie
in terms of numbers of restorations, however this is not a main criteria for judging clinical progress. Any students
that have not achieved a great deal that term should explore the reasons for this and again try to seek positive
solutions.
The termly grade is determined using a mean or modal value of the grades attained over the term and subjective
feedback based upon any personal experiences with the student should be given, again concentrating on the
positive aspects and trying to build on those. If there are any reasons for concern or you would like to discuss a
student further please contact Mr Franklin.

How our undergraduates are taught


For anyone not familiar with the curriculum e.g. practitioners working part time on the clinics, here is a brief
overview.
Since 2004 we have been running an integrated curriculum the essence of this is that basic sciences and
behavioural sciences are taught alongside clinical subjects in a modular fashion.
We start off with and concentrate on the maintenance of health and end with the replacement of teeth. The effect
of this is that students learn in a different order to a more traditional curriculum. Gone are the days when students
treated a complete denture patient first, our students dont learn that skill until year four. The following table
summarises what skills are taught and when, refer to this often as it should give you an idea of what the students
should know or have yet to learn, this is however in constant review and may differ in minor respects from the
published version.

D-7

Autumn term

Year 1

Year 2

Year 3

Year 4

Year 5

Cross infection
control

Caries
recognition

Protaper
system

Rotary protaper

Occlusal splints

Fissure sealants

Molar endo

Re-endo

Orthodontics

Basic cons

Balanced force
technique

Amalgam
GIC
Composite
Pulp capping
Polishing
Occlusal
terminology
Checking
occlusion
Rubber dam

Spring term

Radiography
Obturation
Restoration of
the root filled
tooth

Layered
composite
Management of
toothwear
Composite build
up
Complete
dentures

Crown preps
Temporary
crowns
Impression
taking

Basic intra oral


examination

Interocclusal
records

Immediate
dentures

Simple
impression
taking

Occlusal
examination

Copy dentures

Facebow

Relines /
rebases

Partial denture
design

Paediatric
dentistry

Bridges

Summer term

Local
anaesthesia
Periodontology
Indices
Supra and
subgingival
scaling

Intro to RCT
K-files and
modified
double
flaredtechnique

Simple
extractions

It is highly likely that the students on the clinics may be undertaking a procedure for the first time. Be sure to let your
tutor know if this is the case.
Students will only be allowed to carry out crowns and endodontics after successfully satisfying those sections of
clinical skills B, this will be signified by a signature in their log books on the appropriate tabs which indicate this to be
the case. All staff supervising year 3 students who are embarking upon crown or endo work should be aware of this
and check the log book first.

D-8

Clinical allocations
At the time of writing the allocations to the clinics are shown in the table below
Year 1
Autumn term

Year 2

Year 3

Year 4

Year 5

perio

Cons

Cons

Radiography

Ortho

Restorative
(combine care)

Prosthetics
(partials)

Ortho
Outreach

Paeds

Paeds

ADC/locals

ADC / Locals

Perio

Oral surgery

Radiography

Oral Medicine
Sedation
Medical
emergencies (1
session per
term)

Spring term

Cons

Cons

Cons

Restorative

Perio

Prosthetics
(partials)

Ortho

Outreach

Prosthetics
(Completes)

Paeds

Radiography*

Radiography

Paeds
ADC/ Locals
Radiography

Summer term

ADC / Locals
Oral Surgery
Oral medicine
Sedation

Perio

Cons

Cons

Cons

Restorative

Local
anaesthetic
dresserships

Radiography

Paeds

Ortho

Oral Surgery

ADC/locals

Outreach

Prosthetics
(partials)

Prosthetics
(completes)

Radiography

ADC/Locals

Perio

Oral Medicine

*Note radiography sessions are spread throughout several years and may not be for each student in the terms as
shown
It is important that students use the allocated sessions for the disciplines they are defined for. Conservation sessions
should be mainly for cons work, with some preliminary periodontal treatment as appropriate. Protracted
periodontal treatment should be carried out in the students periodontal clinic sessions or referred to the School of
Hygiene and Therapy. Likewise prosthetic sessions should be used for prosthetic treatment. For partial denture cases
there is often the need for periodontal or conservative treatment prior to the provision of dentures. Those patients
should be seen on the student perio or cons sessions until such a time as the dentures can be started. In the mean
time the student should be allocated another prosthetic case. Students in more senior years can treat two prosthetic
patients in each session.
D-9

Examinations in restorative dentistry


The following examinations take place. **This information is for supervisors simply as an overview, students will be
supplied with more detailed instructions**
Year 3
CP3 case report. The students are given a proforma of a case report to fill in about a patient they have been treating.
The treatment does not need to be complete, but a comprehensive plan, photos, indices, charting and some element
of conservative treatment is required to be carried out.
Anxiety case report. This involves giving a patient the modified dental anxiety scale to fill in and possibly the use of
special techniques to deal with the dental anxiety, eg relaxation techniques, tell show do or in exceptional
circumstances simple hypnotic relaxation. Further details can be obtained by contacting Cath Potter
(C.L.Potter@leeds.ac.uk)
Year 4

Endodontic case report


o A short report about a molar endo case treated, including the radiographs, any apex locator readings
and the associated sheet from the log book
Prosthetic case report
o The presentation of a treated patient and short clinical evaluation and a written case report using a
proforma provided. This will be carried out by a full time member of staff. The case must be
sufficient to show a reasonable amount of work done by the student e.g. a cobalt chrome denture,
c/c case or large partial dentures
Senior operative test
o The students are required to provide a crown for a patient with the clinical procedures of the
preparation, impression and temporary restoration being observed by two members of academic
staff. If any student does not fulfil this during year 4, an assessment week is scheduled near the end
of the year where they are required to provide a more advanced procedure such as a large
restoration under close scrutiny.

Year 5
As part of the final Clinical Practice examination the students create a portfolio of treatment comprising their
Paediatric case plus 3 cases from Restorative / Oral Surgery.
The three cases consist of a long case and two short cases. The long case will be a patient for whom treatment has
been completed. The case should involve some aspect of caries management and periodontal therapy, and
demonstrate that the student can formulate a detailed comprehensive treatment plan in a holistic manner and
demonstrate good clinical and patient management skills. The short cases may be incomplete treatment but add in
some way to the portfolio areas of patient care and management not covered by the long case. One of the short
cases must involve laboratory work.

D-10

Restorative Clinical Procedures


Record keeping.......................................................................................................................................................... E-1
Dental hospital records and treatment .................................................................................................................. E-1
Consent ................................................................................................................................................................... E-1

Record keeping
Dental hospital records and treatment
NO TREATMENT SHOULD BE COMMENCED WITHOUT THE STUDENT FIRST SEEKING ADVICE FROM THE
SUPERVISING MEMBER OF STAFF.
Students should not retain records themselves. Records of
patients currently under treatment are retained in Reception
whilst the remainder are kept in Central Records.
Diagnostic Sheets (Buff):
These are completed for each patient attending for the first
visit in either Periodontology, Prosthetics or Restorative
Clinic. The sheet is inserted into the patient's treatment
record card in the section provided for diagnostic and report
sheets.
Detailed treatment notes must be recorded on the white
treatment record sheets for each visit and signed by a
member of the staff (copy available at Appendix).
A full and clear but concise account of treatment provided at
each attendance should be noted, recording all significant
details, i.e. local anaesthetics given (including drugs, dosage,
expiry date and batch number), tooth treated, type of cavity,
any complications such as pulpal exposure, materials used.

e.g. Medical history checked and clear,


consent gained for LA and restoration of LL6
using amalgam, patient warned that
radiograph shows caries is deep and that RCT
may be an option. EPT shows pulp to be vital.
Left inferior dental block, 1.8 ml 2%
Lignocaine with 1:80000 Adrenaline (batch
number, exp date).
Rubber dam placed. LL6 MOD cavity, near
exposure of mesio-buccal pulp horn, Calcium
Hydroxide as indirect pulp cap, GIC base,
Amalgam restoration. Occlusion checked.
Patient warned re: LA and possible
consequences of pulpal involvement. Next
visit, check status of LL6 and restore LR6.

All entries should be signed by both student and supervisor with a printed name and year / grade beneath the
signature
As well as the student and staff names written legibly there should also be made a note of in which chair the patient
was treated.

Consent
After an explanation of the proposed treatment plan to the patient the notes should record that the patient has
agreed to the treatment outlined in the plan. Where there are a number of options these should be outlined to the
patient with the advantages and disadvantages, and a record that this discussion has taken place should be made.
E-1

Restorative Clinical Procedures


History, examination, diagnosis and treatment plan ......................................................................................... F-2
History .................................................................................................................................................................... F-2
Referral (Ref)...................................................................................................................................................... F-2
Complaint of (C/O) ............................................................................................................................................. F-2
History of the presenting complaint (HPC) ........................................................................................................ F-2
Past dental history (PDH) ................................................................................................................................... F-2
Social history (SH) .............................................................................................................................................. F-2
Medical history (MH) ......................................................................................................................................... F-2
Charting .................................................................................................................................................................. F-2
Examination............................................................................................................................................................ F-3
Periodontal screening ........................................................................................................................................ F-3
Extra-oral examination ...................................................................................................................................... F-3
Occlusion............................................................................................................................................................ F-4
Dentures ............................................................................................................................................................ F-4
Special tests ....................................................................................................................................................... F-4
Radiographic report ........................................................................................................................................... F-5
Diagnoses................................................................................................................................................................ F-5
Treatment Plan ....................................................................................................................................................... F-5
The likely sequence............................................................................................................................................ F-5
Emergency treatment................................................................................................................................... F-5
Pre-treatment baseline indices and records ................................................................................................ F-6
Stabilisation phase ........................................................................................................................................ F-6
Initial reassessment ...................................................................................................................................... F-6
Definitive treatment ..................................................................................................................................... F-7
Continual review and maintenance.............................................................................................................. F-7

F-1

History, examination, diagnosis and treatment plan


History
History taking follows a recognised plan that is outlined on the buff coloured history and examination forms.
The sections on the form should be filled out as follows:

Referral (Ref)
Where the patient has been referred from, which consultant / waiting list, GDP/GMP or self-referral.

Complaint of (C/O)
A summary of the patients complaints, where possible using the patient's own words.
Pain history may be assisted using the SOCRATES acronym:
S = Site, how well localized
O = onset, spontaneous or stimulus
C = character sharp or dull
R = radiation, does the pain spread
A = associated factors such as swelling, sinus or systemic involvement
T = timing, how long does the pain last, does the nature of the pain change throughout the day
E = exacerbating / relieving factors
S = severity

History of the presenting complaint (HPC)


This is where the background to the presenting complaint(s) are written in digest form.

Past dental history (PDH)


A record of the patient's normal attendance pattern, oral hygiene regime, previous experiences at the dentist and if
a denture wearer a full denture wearing history including the age of the current denture, and how many previous
sets over how many years.

Social history (SH)


The patient's occupation, alcohol and tobacco habits as well as their ability to attend.

Medical history (MH)


A synopsis of the main / relevant findings of the medical history as well as an indication of the need to study the
medical history in more detail where necessary.
Following history taking, the student should approach the supervising member of staff to discuss the findings and
receive permission to carry on with the examination.

Charting
The charting should be carried out in accordance with the conventions detailed bellow. The charting should be
checked and signed and dated by the supervising tutor.
F-2

Examination
Periodontal screening
A Basic Periodontal Examination (BPE) should be carried out and further periodontal charts should indicate the
number and site of pockets greater than 6mm and any mobility detected. A BPE of 3 in any sextant will indicate that
a more thorough periodontal examination may be required.

Extra-oral examination
Here can be comments regarding:

The general demeanour.


Signs of illness or anxiety.
Asymmetry.
Skin lesions on face or perioral tissues.
Clicks / crepitus of TMJs on opening and closing, limitation or deviation of the mandible when opening.
Evidence of tenderness in the insertion / origin of any of the muscles of mastication.
Salivary glands.
Lymphadenopathy.

F-3

Occlusion
Make a record of the patient's:

Skeletal pattern.
Occlusal scheme i.e. canine guidance or group function where applicable.
Whether ICP and RCP are coincident and the nature of the slide between the two.
Any signs of dento-alveolar compensation or over-closure due to toothwear.

Dentures
Comment upon:

Type of dentures.
Retention / stability / effectiveness of current dentures.
Denture bearing area.
Saliva.

Special tests
Tenderness to percussion (TTP), Fibre-optic transillumination (FOTI), Electric pulp test (EPT), Application of heat /
cold (ethyl chloride), Tooth sleuth (available from dispensary).
1. Ethyl chloride is available from dispensary.
2. Spray on a small cotton pellet.
3. Apply to dry tooth on cervical area and wait a few seconds for the patients response. Write down if positive
or negative response in the patients notes.

1.

2.

3.

1. Electric pulp test (EPT) is available from dispensary.


2. Apply lubricant to the tip of the EPT.
3. Apply to dry tooth on cervical area. Do not touch the soft tissues.
4. Ask patient to hold on to the end of the EPT handle and instruct patient to let this go once stimuli is felt.
Write down the tooth and number displayed on the EPT screen in the patients notes.

1.

2.

3.

F-4

4.

Radiographic report
Students should be encouraged to carry out a radiographic report on any radiographs taken as part of the initial
assessment. More information about radiographic selection criteria and guidelines to write a report are available in
'Radiographic assessment'.

Diagnosis
All diagnoses to be listed which should form the rationale for the ensuing treatment plan.

Treatment Plan
Finally, a detailed treatment plan should be devised and written in the space provided for staff approval. The order
of treatment planned should be executed in the sequence determined with no major alteration undertaken without
the agreement of the authorising member of staff. It is not necessary to list the order of individual restorations
although it may be appropriate to indicate which should be treated as a matter of priority if this is warranted.
Before establishing the treatment plan, the following should be discussed with the patient right after history and
examination has taken place and a record of both the discussion and the outcome should be recorded in the
patient's notes:

Diagnosis.
All alternative treatment options for a given problem.
Any risks associated with the options discussed.
The likely longevity of a restoration or procedure (care should be taken that this is not stated as, nor could
be interpreted as a guarantee).
Any potential consequences of choosing not to treat and keep under observation.
What the patient must do and agrees to do themselves to care for their oral health and/or any proposed
restoration or procedure.
Any treatment declined.

As a general rule treatment should be ordered thus:

Treatment of pain / emergencies.


Baseline indices / records.
Stabilisation of oral disease, dressing active caries and cause related periodontal therapy removal of
PRFs and OHI.
Restoration phase.
Reconstructive phase.
Replacement phase.
Monitoring / maintenance.

Treatment Plan - The likely sequence


By all means this is not an exhaustive list and it is here with the only intention to serve to students as a quick revision
material when developing a treatment plan. This should be developed according to the patient's needs.
1. Emergency treatment - Pain relief!
1. Extraction.
F-5

2.
3.
4.
5.
6.

Pulp extirpation.
Antibiotic therapy.
Incision and drainage.
Temporary dressings.
Other emergency measures.

2. Pre-treatment baseline indices and records


Based on your diagnosis collect additional information as appropriate:
Study models.
Diet analysis.
For diagnosis of gingivitis:
o Plaque free scores (PFS), as often as required.
o Marginal gingival bleeding free scores (MBFS).
For diagnosis of periodontitis:
o Plaque free scores (PFS), as often as required.
o Probing pocket depth (PPD).
o Bleeding on probing (BOP).
o Suppuration, furcation involvement, mobility and recession.
Further radiographic examinations (it is assumed that all required radiographs were already taken during
history and examination, but if needs be further investigations should be carried out at this stage).
3. Stabilisation phase (this could be longer than 6 months)
1. Prevention: (Preventive strategies should be the priority in this stage)
Most common preventive measures are:
Oral hygiene instruction.
Fluoride supplements (toothpaste, mouth rinse, gels, varnish).
Smoking cessation.
Individual diet counselling.
Fissure sealants.
2. Extraction of hopeless teeth.
3. Removal of iatrogenic factors (overhanging restorations and other plaque retentive factors).
4. Non-surgical periodontal treatment (NSPT), monitor and motivate!
5. Restoration of carious teeth and/or treatment of failed restorations (patient confidence and motivation
can be encouraged by some simple, aesthetic restorations, even if they are only temporary in nature).
6. Preliminary endodontics.
7. Provisional prostheses.
4. Initial reassessment
1.
2.
3.
4.
5.
6.
7.

Periodic bitewing radiographs.


Assessment of compliance with preventive advice.
Reinforce preventive advice.
Periodontal indices.
Assessment of heavily restored teeth.
Consider further stabilization.
Consider definitive treatment.
F-6

5. Definitive treatment
Definitive treatment should not be provided until stabilization of active disease has been demonstrably achieved.
Baer in mind that if definitive treatment is provided before achievement of good OH for example we might be
accelerating the patient's loss of remaining teeth!
1. Crown and bridge work.
2. Aesthetic or cosmetic treatment (place definitive restorations/crowns with rest seats and undercuts as
required for denture).
3. Surgical periodontology.
4. Metal based partial dentures.
6. Continual review and maintenance
1.
2.
3.
4.
5.
6.
7.
8.
9.

Periodic bitewing radiographs.


Follow-up radiographs of endodontic treatment (at least one year from final obturation).
Follow-up radiographs of dental implants.
Assessment of heavily restored teeth.
Assessment of compliance with preventive advice.
Reinforce preventive advice.
Periodontal indices.
Consider return to stabilization if necessary.
Maintenance of removable denture.

F-7

Restorative Clinical Procedures


Preoperative considerations.................................................................................................................................. G-1
Moisture control ................................................................................................................................................... G-1
Rubber Dam........................................................................................................................................................... G-1
Matrix and wedging .............................................................................................................................................. G-2
Facebow recording ................................................................................................................................................ G-3
Interocclusal records ............................................................................................................................................. G-3
Choice of articulator.............................................................................................................................................. G-4

Preoperative considerations
Moisture control
Cotton wool rolls, Dry Tips and rubber dam should be used appropriately. When
using rotary instruments the students should not be working unassisted. The
assistant should use the wide bore aspirator to help maintain a clear field as well
as soft tissue retraction.
When working in the lower arch the students should always us the 'tongue guard'
type of saliva ejector.
Figure G1 - Tongue guard saliva ejector.

Rubber dam
Students are encouraged to use rubber dam for all restorations and it is mandatory during endodontics. They are
taught a winged technique. For routine conservation of posterior teeth we teach to clamp the tooth behind the one
being treated and using wedgets to secure the dam anteriorly.
All clamps should be adequately flossed prior to placement in the mouth and the floss should drape from the mouth
at all times. There have been several incidents of clamps fracturing during use.
Method:
For conservation work:
For Molars and Premolars
1. Stamp the rubber sheet (latex free dam is also available).
2. Punch one hole for the tooth being treated and (ideally) include one
tooth posterior to this and two anteriorly.
3. Floss between teeth to ensure adequate ability to pass through.
4. Tie floss to appropriate winged clamp.
5. Try clamp in without trauma to gingiva, clamp should fit tightly with
at least 4 points of contact on the tooth
G-1

Figure G2 - Floss must be tied to clamp.

6. Remove clamp and attach to rubber sheet in the most


posterior hole.
7. Place over and clamp the tooth posterior to the tooth being
treated.
8. Attach frame.
9. Place other teeth through the remaining holes.
10. Place wedget between the mesial aspect of the most
anterior tooth included in the rubber dam and the adjacent
tooth.
11. Rubber sheet should not be taut.
Figure G3 - Rubber dam in place - note floss should be
tied around clamp not as shown.

For anterior teeth (we also have dry dam)


1. Punch holes for all 6 anterior teeth.
2. Stretch holes over the teeth.
3. Secure with wedgets between canines and premolars.
For endodontics:
For all teeth
1.
2.
3.
4.

Figure G4 - Rubber dam - Anterior cons technique.

Stamp the rubber sheet (latex free dam is also available).


Punch one hole for the tooth being treated and place over it.
Secure with butterfly or appropriate clamp (incisor / premolar / molar).
Apply Oraseal around the tooth / dam interface.

For endodontic treatment students should only clamp and


expose the tooth being treated, the use of 'OraSeal' is
mandatory when using hypochlorite.
Matrix and wedging
Virtually every approximal restoration will require use of a cellulose acetate matrix (anterior tooth) or a metal matrix
band (posterior tooth). Matrix bands are also useful when restoring posterior teeth with at least one missing wall
besides the approximal area(s). Clear matrix bands are also available from dispensary but should only be used where
there is not an adjacent tooth.
A wedge should be placed whenever a matrix is required, the wedge should adequately seal the gingival margin of
the approximal box and slightly push the teeth apart. In posterior teeth the metal matrix band should be burnished
to aid on creation of a good contact point.

Omni (dispoable matrix)

Tofflemire
G-2

Siquveland matrix

Facebow recording
We use the Denar slidematic facebow system. Staff trained with a different system are invited to attend one of our
regular 'Facebows and Articulators' CPD events.
Stages:
1. Using the occlusal plane locator mark a point on the right side of the nose 42mm above the right lateral
incisor edge.
2. Soften beauty wax and apply a double layer to the top surface of the bite fork.
3. Gently position the bite fork over the upper teeth making sure to keep the middle of the fork to the patient's
midline and the prong pointing out straight forward below the patient's right eye.
4. Remove the fork and allow the wax to cool.
5. Reinsert the bitefork making sure it is firmly in place, get the patient to stabilise with their thumbs.
6. Attach the transfer jig to the ear bow. Slide the jig over the prong of the bitefork and guide the ear pieces
into the patient's ears.
7. Adjust the height so that the pointer on the earbow is level with the mark made earlier on the patients nose.
8. Tighten nut one then nut two.
9. Remove from the mouth and tighten both nuts again, make sure the jig cannot move.
10. Disassemble from ear-bow.
11. Disinfect in Perform for 10 minutes.

Interocclusal records
RCP record

Use double thickness of Moyco extra hard beauty wax, soften in warm water, guide the patient into
retruded position, do not allow the patient to bite all the way through the wax.

Use RCP records for:


o
o

Examination of the occlusion.


Reorganisation cases.
Changes being made to major guidance scheme.
Changes to OVD.
No stable ICP.
Construction of therapeutic splints.

ICP record

Stable ICP recording material (e.g. Blu Mousse) over preps only.
Unstable models due to lack of teeth use record rims in edentulous spaces.
Do not use squash bites.

Use ICP records for:


o

Conformative cases.

G-3

Choice of articulator
Semi adjustable (set to average values)

Bridgework.
Examining the occlusion.
Therapeutic splints.
Any case where the determinants of occlusion (ICP, OVD, Major guidance) are lost due to preps or having
planned changes.
Multiple anterior crowns (with custom incisal guidance table) or multiple posterior crowns ( 3).

Should be considered for:


o Crowns on last standing teeth in the arch.
o Teeth carrying occlusal guidance (e.g. canines or incisors).
o Teeth in group function.

Average Value

Partial and complete dentures.


Multiple crowns in conformative case.

Simple Hinge

Single crowns in bounded sites with canine guidance present.

G-4

Restorative Clinical Procedures


Routine restorations ............................................................................................................................................... H-2
Choice of restorative materials.............................................................................................................................. H-2

Caries removal (equipment required & step-by-step guide) .............................................................................. H-3


Amalgam .............................................................................................................................................................. H-4
Occlusal amalgam ............................................................................................................................................ H-4
Approximal amalgam ........................................................................................................................................ H-4
Equipment required & step-by-step guide ....................................................................................................... H-4
Bonded amalgam ............................................................................................................................................. H-6
Replacement amalgam .................................................................................................................................... H-6
Carving .............................................................................................................................................................. H-6
Polishing............................................................................................................................................................ H-6

Resin composite .................................................................................................................................................. H-7


Case selection and management ...................................................................................................................... H-7
Shade taking ..................................................................................................................................................... H-7
Equipment required & step-by-step guide ....................................................................................................... H-8
Bevelling............................................................................................................................................................ H-9
Bonding ............................................................................................................................................................. H-9
Composite placement ....................................................................................................................................... H-9
Finishing and polishing ................................................................................................................................... H-10
Core build up................................................................................................................................................... H-10
Bulk fill composite (SDR - Step-by-step guide) ............................................................................................... H-10

Glass ionomer cements .................................................................................................................................. H-12


Shade taking ................................................................................................................................................... H-12
Use and indications......................................................................................................................................... H-12
Traditional glass ionomer cement (GIC) .................................................................................................... H-12
Resin Modified glass ionomer cement (RMGIC)........................................................................................ H-12
Dentine conditioner (cleansing) ..................................................................................................................... H-12
Trituration / mixing ......................................................................................................................................... H-13
Matrix.............................................................................................................................................................. H-13
Finishing .......................................................................................................................................................... H-13
Core build up................................................................................................................................................... H-13

Clinical guidelines for bases / liners ................................................................................................................... H-14


H-1

Liners .................................................................................................................................................................... H-14


Pulpal exposure.................................................................................................................................................... H-14

Pulp protection materials available in the department ................................................................................. H-14


Setting calcium hydroxide (Dycal)........................................................................................................................ H-14
Non-setting calcium hydroxide (Hypocal)............................................................................................................ H-14
Glass ionomer cement (Fuji Liner) ....................................................................................................................... H-14
Bonding systems (Optibond solo Plus) ................................................................................................................ H-14
Ledermix ................................................................................................................................................................... H-14
Kalzinol (zinc oxide eugenol) ..................................................................................................................................... H-14

Routine restorations
Choice of restorative materials
The range of restorative materials available includes:
Amalgam.
Resin Composite (Herculite XRV, Ceram-X Duo).
Traditional GIC (Fuji Triage (pink), ChemFil Rock).
Resin modified GIC (Fuji II LC).
In general the following indications for use should be considered:
Amalgam
o Large posterior load bearing cavities.
o Patients with high risk of caries.
o Subgingival margins.
o Moisture control is difficult.
o Cores for crowns.
o Posterior intra canal dowel preps (Nayyar technique).
Resin Composite
o Anterior and posterior restorations where aesthetics are important.
o When all margins are in enamel.
o Incisal edge restorations.
o Build ups to treat tooth wear.
o Creation of undercuts for partial dentures.
o Repair of fractured teeth.
o Posterior interproximal restorations where the base of the box is supragingival.
o Closing of diastemas and reshaping teeth.
Traditional GIC
o Temporary restoration in high caries rate stabilization phase.
o Temporization during endodontic treatment.
Resin modified GIC
o Cervical lesions where moisture control is problematic or margins are in dentine.
o Root caries.
o Approximal lesions in anterior teeth where aesthetics are unimportant.
H-2

Caries removal
Equipment Required (Dispensary):

Equipment Required (Blue Trolley):

Local anaesthetic cartridge

LA syringe and needle


High / Slow speed handpiece
No.7 high speed diamond bur
Rose head slow speed burs
Cons kit

Equipment Required (In Surgery):


Topical anaesthetic

Process
1. Administer topical and local anaesthetic.
2. Access caries through enamel using high speed hand-piece and diamond bur:
o Begin at a point central to caries and widen enamel access until a clear ADJ becomes apparent.
o Should caries extend proximally leave thin proximal enamel (then fracture this with excavator to avoid
iatrogenic damage to adjacent tooth) or break through to clear this area.
o Purely proximal caries on posterior teeth should be
managed with a 'slot' approach, removing minimal
amounts of tooth tissue to access the caries only.
3. Remove infected dentine (soft / leathery, yellow / brown
colour) using excavators and slow speed rose head burs,
until a solid, scratchy surface is felt throughout with a
sharp probe. Never use the high speed to remove caries!
4. Leave affected (hard & scratchy, any colour) dentine
behind.
5. If getting close to the pulp but tooth is symptomless and
vital consider stepwise excavation (and rubber dam if not
Figure H1 - Preparation for 'slot' composite.
already in use).
6. Ensure ADJ is caries free throughout cavity.
7. Check cavity design is appropriate for intended restorative material and restore.

Access through enamel


central to caries.

Widen enamel access to


clear the ADJ.

Remove caries completely


from cavity walls.

H-3

Finally clear the floor of


the cavity leaving affected
dentine behind.

Amalgam
The dental amalgam used on clinic is a high copper alloy with decreased gamma 2 phase (The phase responsible for
increased corrosion, creep and ditching). It is encapsulated for improved mercury hygiene. Capsules with grey
plunger (20g alloy, 20g mercury) should be sufficient for small restorations while capsules with green plunger (alloy
30g, mercury 30g) are available for larger restorations. They are mixed in the Silamat amalgamator for 5 seconds.
Sealable jars are located in each cubicle for disposal of surplus amalgam, capsules and contaminated dappens pots.

Occlusal amalgam
The students are taught minimal preparation techniques with the paramount concern being the preservation of
tooth structure. Cavity preparation is limited to removal of carious tissue and minimal modifications to provide
undercut for retention and removal of gross unsupported enamel overhangs.

Approximal amalgam
In the absence of occlusal caries an approximal 'slot' is taught with the use of pits or grooves to aid retention if
required.
If there is also an occlusal lesion the 2 portions of the cavity are connected to aid retention via an isthmus area.
Disposable matrix bands are used as standard, for deep boxes Tofflemire and Siquveland matrix bands are available,
these should be used with wedges to prevent ledge formation.

Equipment required & step-by-step guide (amalgam restoration)


Equipment Required (Dispensary):

Equipment Required (Blue Trolley):

Local anaesthetic cartridge


Lining material RMGIC (Fuji Lining)
Bonding material Panavia* or RMGIC (Fuji
Lining)
Amalgam capsule
Wooden wedges

LA syringe and needle


High / Slow speed handpiece
No.7 high speed diamond bur
Rose head slow speed bur
Amalgam carrier
Dappens pot
Cons kit
Matrix band

Equipment Required (In Surgery):


Topical anaesthetic
Articulating paper

*Should Panavia be required, this is available by asking a member of the nursing team.

Process
1.
2.
3.
4.

Administer topical and local anaesthetic.


Moisture control (rubber dam or cotton rolls and appropriate suction in selected cases).
Complete caries removal as per guidance in 'Caries removal' section.
Check if general guidelines for cavity preparation for amalgam restorations were met:
o At least 2mm deep for adequate strength.
o Wide enough to enable use of the smallest packer.
o Cavo-surface angles of > 90.
o Amalgam margin angles > 70.
o No unsupported enamel.
H-4

5.

6.

7.

8.

9.

10.
11.
12.

o Rounded internal angles.


Check the cavity design for retention:
o Is there sufficient undercut to retain amalgam?
o Are additional grooves or cavity wall modifications required to
improve retention or is a bonded restoration indicated?
Check the cavity design for resistance:
o Is there a satisfactory occlusal key or do the cavity design
provides resistance form already?
o If not can features such as dovetails and grooves be added to aid
this, or is a bonded restoration indicated?
o Is the floor of any box flat to offer vertical resistance under
occlusal loading?
If the cavity extends interproximally:
o Width should just clear contact area.
o Bottom of box must be bellow contact point.
o The gingival wall should be level, not slopping.
o Matrix band must be placed over the tooth ensuring it sits beyond
all cervical cavity margins, then apply wedge and burnish matrix
band to create contact point.
Assess need for cavity liners:
o If the cavity is shallow no liner is required.
o Moderate to deep: apply RMGIC liner (Fuji Lining).
o Pinpoint pulpal exposure: apply setting Ca(OH) 2 in the area then
RMGIC liner (Fuji Lining).
* Keep lining materials away from enamel.
If cavity is considered unretentive a thin layer of dual-cure resin
cement (RMGIC liner, Panavia or Rely-X) should be placed over all
walls, on dentine but not over enamel.
Mix amalgam, dispense capsule content in a Dappens pot, load the
amalgam carrier and place amalgam into the cavity.
Firmly compact the amalgam into the deepest parts of the cavity first
(initial packer has to fit into the cavity and interproximal boxes floor).
Once the cavity is full to the margins (use adjacent marginal ridges as
a guide for amount of amalgam likely required in class II restorations),

begin shaping. Clear the inner periphery of matrix bands with a sharp
probe, remove the band then begin occlusal contouring with a
Ward's Carver, burnisher.
13. Check occlusion and finish.

Figures H2 - Features of a cavity preparation


for amalgam.

H-5

Bonded amalgam
We discourage the use of dentine pins.
In cases where there has been cuspal loss and retention may be compromised, bonding the amalgam may be of
benefit, though currently available evidence is equivocal, where retention cannot be gained adequately from the
cavity preparation we encourage the use of bonding. The technique we use is to line the prepared cavity with RMGIC
(Fuji liner) and pack the amalgam onto it while still wet i.e. don't light cure it.
Procedure
1.
2.
3.
4.
5.

Prepare cavity.
Incorporate pits and grooves in non-danger areas i.e. avoiding pulpal or furcal exposure.
Apply matrix band.
Wedge then burnish.
Apply an extremely thin layer of RMGIC lining material (Fuji liner) to dentine only up to the ADJ using a
Thymozin probe, it shouldn't be so thick as to be squeezed out to the tooth surface during amalgam packing.
6. At the same time, the assistant should triturate the amalgam.
7. Pack amalgam on unset lining material.

Replacement amalgam
If possible the students are taught to repair amalgams with composite / glass-ionomer or key into an existing
restoration.
Ditching is not an indication for replacement unless there is recurrent caries or if it creates a plaque trap that cannot
be eliminated by polishing, or repair with GIC or fissure sealant.

Carving
Students are taught to carve using the remaining tooth morphology as a guide. Deep or sharp occlusal anatomy
should not be encouraged, but marginal ridges and occlusal spillways should be maintained.

Polishing
Polishing is no longer taught as a routine step in amalgam provision; however we do encourage the use of burnishing
burs to improve marginal continuity in old restorations rather than replacement.

H-6

Resin Composite
There are two resin composites in current use. Herculite XRV Ultra is a nano hybrid suitable for anterior and
posterior restorations and Ceram-X duo with greater translucency is perfect for highly aesthetic cases.
Herculite XRV Ultra enamel capsules are grey and dentine capsules are black.

Case selection and management


Patients should demonstrate good oral hygiene before placement of composite restorations, if this is not the case,
these might benefit from provisional restorations with GIC / RMGIC. If definitive restorations are required and
improvements in plaque control are not observed, amalgam restorations should be indicated.
If caries extends beyond enamel in the gingival aspect of the box either a GIC, to build the surface supragingivally,
should be used prior to composite placement or amalgam should be placed.
If an occlusal surface is to be restored occlusal contacts should be marked with articulating paper to determine the
likely loading of the composite restoration. Composites are preferred in small, non-load bearing areas to avoid
excessive occlusal wear.

Shade taking
This should be performed on a clean tooth before rubber dam application. For restorations in the aesthetic zone,
involve patient in the shade selection process, give them a mirror and ask for their opinion.
For more accuracy, especially in critical areas, shade taking should be carried out as follows:
1. Use Vita Shade to gauge an idea of the
tooth shade e.g. A2.
2. Select composite equivalent to the
selected Vita Shade plus a darker and a
brighter shade e.g. A1, A2 and A3.
3. Place one small blob of each composite
shade on the incisal area (to assess
enamel shade) and cervical area (to
assess dentine shade), preferably on
tooth to be restored.
4. Light cure it for 20s and gently apply
some of the patient's saliva over the
composite blobs.
5. Write down chosen shade on patient's
notes.

Figure H3 - Enamel shade taking.

Ceram-X duo equivalent shades based on Vita scale (top Vita, bottom Ceram-X duo equivalent shade):

H-7

Equipment required & step-by-step guide (composite restoration)


Equipment Required (Dispensary):

Cons kit
LA syringe and needle
High / Slow speed handpiece
No.7 high speed diamond bur
Rose head slow speed bur
Shade guide
Composite dispensing gun
Matrix band (if posterior)
Composite finishing equipment:
o Fine / Ultrafine diamond burs
o Soflex discs and mandrel
o White stone
o Interproximal finishing strips
o Diamond polishing pastes

Equipment Required (Blue Trolley):

Local anaesthetic cartridge


Mylar strip (if anterior)
Wooden wedges
Etchant gel
Microbrushes
Dentine bonding agent Optibond Solo
Composite compule
Equipment Required (In Surgery):

Topical anaesthetic
Articulating paper

Process

Administer topical and local anaesthetic.


Moisture control (rubber dam, dry dam (can be used on anterior teeth) or cotton rolls and appropriate suction
in selected cases).
Complete caries removal as per guidance in 'Caries removal' section.
Whenever possible the cavity preparation should maintain any mechanical retentive features which have arisen
as a product of caries removal.
Check the cavity for any unsupported enamel.
Ensure that internal angles are rounded.
Bevel:
o Anterior tooth: bevelling of of the thickness of the labial enamel to a distance approx. 1mm from the
cavity margin.
o Posterior tooth: no bevel!
If the cavity extends interproximally:
o Anterior tooth: place matrix strip and apply wedge to secure.
o Posterior tooth: place matrix band over the tooth, ensuring the band sits beyond all cavity margins, apply
wedge and burnish matrix band.
Assess need for cavity liners:
o In general a liner is not required.
o Pinpoint pulpal exposure: apply setting CaOH in the area then RMGIC liner (Fuji Lining).
* Keep lining materials away from enamel.
Etch and bond:
o Etch both enamel and dentine for 15s with 37.5% Phosphoric acid gel.
o Rinse thoroughly for 15 - 20s.
o Dry lightly to remove excessive moisture but do not desiccate (5s).
o Apply 'OptiBond Solo Plus' to both enamel and dentine surfaces with applicator tip for 15s, using light
brushing motion.
o Gently thin with a stream of air for 3s.
H-8

o Light cure for 20s.


Place 2mm thick composite increments and light cure for at least 20s each increment until cavity is restored.
When the restoration includes an incisal edge it is common practice to over-build the incisal edge and then
finish / polish down as necessary.
Finish - To get the right shape.
Polish - For a glossy and smooth surface.
Check Occlusion.

Bevelling
On anterior teeth, if cavity extends labially, bevelling should be performed to allow better aesthetics in the transition
between tooth and restoration. Whereas in posterior teeth no enamel bevelling should be performed.

Bonding
We currently use Optibond Solo Plus Total-Etch adhesive. The material describes itself as 'single component' which
means it contains both PRIMER and ADHESIVE, it is not self-etching.
The 'Total-etch' wording relates to the fact that etching should be carried out simultaneously to enamel and dentine.

Composite placement
We teach the students to first build up the proximal wall and marginal ridge. The remained of the cavity should be
filled in increments of less than 2mm and composite placed in a herring-bone fashion.

H-9

Figure H4 - Stages in posterior composite placement.

Finishing and Polishing


Marginal and occlusal finishing should be performed using white and green stones. Graded Soflex discs (course to
fine) are also available for finishing of accessible surfaces and interproximal strips as the name suggests for
approximal areas. Enhance kit is also available as well as diamond impregnated polishing paste.
Following finishing and polishing the surface should be re-cured for an additional 20s.

Core build up
Composite may be used as a core material but it is suggested that any impressions are delayed for 1 week following
placement. This will allow hygroscopic expansion to occur before preparation rather than during the period that the
crown is being constructed.

Bulk fill composite


We have recently introduced a bulk fill composite (Dentsply SDR) into the armamentarium of the dental students.
This is to be used as an alternative to a layering technique for Occlusal and approximal posterior restorations.
SDR Step-by-step guide

1. Completed cavity. Deal with any


pulp cap or indirect pulp cap as
appropriate.

2. Place metal Matrix band to seal


base of box and also be 2mm
higher than marginal ridge.

H-10

3. Wedge tightly in place and


burnish against adjacent tooth at
position of desired contact point.

4. Etch whole of cavity and


surrounding enamel for 15
seconds, then wash and lightly
dry, until no obvious pools of
water, do not to over-dry.

5. Apply bonding agent to whole of


cavity (including over RMGIC if
pulp cap was placed).

6. Gently blow with air from 3-in-1,


Light cure for 10 seconds.

7. Place tip of SDR compule into


deepest part of cavity.

8. Keep tip in deepest area whilst


injecting SDR in increments no
more than 4mm. Leave 2mm
space occlusally for composite
cap.

9. Light cure each increment for 20


seconds.

10.Build up occlusal anatomy with


regular enamel shade composite.

11.Light cure each increment for 20


seconds.

12.Remove matrix band, adjust


occlusion, check for overhangs
and tightness of contact.

H-11

Glass ionomer cements


The materials which are currently available include:

Fuji II LC

(Resin modified) for aesthetic restorations in non-load bearing areas where


moisture control is a problem

Chemfil Rock
Fuji Triage (Pink)

Traditional GIC, white and orange coloured respectively for temporisation during
endodontics and for stabilisation of caries

Fuji liner

RMGIC lining material

Shade taking
This should be performed on a clean, wet tooth before rubber dam application. The patient should be informed of
the relative opacity of the initially placed cement if the restored tooth is easily visible.
Use and indications

Traditional glass ionomer cement (GIC)


GIC is an excellent sealer of dentine and therefore is ideal as a temporary restorative in endodontic cases. Fuji Triage
(pink) and Chemfil Rock (contrast white) can easily be removed without undue cavity enlargement due to its bold
colour in comparison to tooth. GIC is also more moisture tolerant than resin composite and so is useful where caries
extends below the CEJ and margins on sound enamel cannot be achieved.
It is relatively weak and has poor abrasion resistance, it should not therefore be used in load bearing areas unless as
a short term temporary material and is not as aesthetic as composite for approximal anterior restorations.
Conventional GIC are very moisture sensitive during and immediately after placement. 2 coats of varnish or unfilled
composite resin should be applied (and cured if appropriate) immediately following restoration.

Resin modified glass ionomer cement (RMGIC)


Whilst resin modified glass ionomer cements offer superior aesthetics to traditional GICs, they should not replace
composite if aesthetics are important and composite is not contraindicated. If glass ionomer is being chosen for it
potential benefits of bonding to dentine and fluoride release then resin modified GIC does not perform as well as
traditional GIC.
RMGIC should only be used for anterior restorations near the aesthetic zone where composite bonding cannot be
reliably performed and as a liner underneath restorations. As it is a true glass ionomer RMGIC will eventually cure in
the absence of light. Evidence shows that the material acts more like a glass ionomer in terms of chemical adhesion
to dentine and ion exchange only until light curing has taken place, following that these benefits are lost and the
material behaves more like a resin composite chemically, but lacking composites strength and durability. It is
therefore advised that light curing is delayed for as long as is feasible.
Light curing should be performed for at least 40s following bulk placement of RMGIC. Following finishing the surface
should be re-cured for an additional 20s.

Dentine conditioner (cleansing)


This is recommended for all conventional GIC using an application of dentine conditioner (10% polyacrylic acid for
15s then wash for 10s and air dry) to remove the superficial smear layer and improve wetting of the cavity.
H-12

Trituration / mixing
This should be performed by adhering to the manufacturer's instructions. However, it may be necessary to prolong
the working time of the encapsulated cements by triturating for only 6-7s for inexperienced students.

Matrix
Glass-ionomer restorations have improved surface characteristics when placed against a matrix and therefore these
should be used whenever possible.

Finishing
Marginal finishing should be performed using graded Soflex discs.

Core build ups


GIC is not recommended as a core build up material, use composite or amalgam.

H-13

Clinical guidelines for bases / liners


Liners
Liners are not routinely used for composite or GIC restorations. For Amalgam restorations an RMGIC liner (Fuji liner)
may be used if the cavity is deep.

Pulpal exposure
If the exposure is small and the tooth was previously symptomless then setting calcium hydroxide should be placed
directly over the exposure site and sealed in with RMGIC (Fuji liner).
The restoration should then be placed as normal.

Pulp protection materials available in the department


Setting calcium hydroxide (Dycal)
Does not reduce microleakage. Cytotoxic.
Needs to be sealed in with another material such as GIC / RMGIC.
Indications: Vital pulpal exposure.
Non -setting calcium hydroxide (Hypocal)
Bacteriocidal, pH of 12.5 allows pulpal recovery if exposure has occurred.
Indications: Pulpal exposure or suspected exposure. Requires stabilising before placement of restoration
(e.g. Kalzinol or GIC).
Glass ionomer cement (Fuji Liner)
Slightly cytotoxic and antibacterial. Adhesive, markedly reduces microleakage.
Indications: Most circumstances to reduce microleakage associated with composite or amalgam
restorations. Good for stabilising non-setting CaOH pulp cap.
Should not be placed over direct pulp exposure.
Bonding systems (Optibond solo Plus)
Slightly cytotoxic and antibacterial. Reduces microleakage with composite restorations.
Indications: As liner under composite restorations.
Should not be placed over direct pulp exposure.

Ledermix
Ledermix is available for the dressing of teeth with irreversible pulpitis and pulp extirpation is not possible due to
failure of anaesthetic. It should be used as a dressing only and not as a permanent lining underneath restorations.
Evidence shows that Ledermix cannot change the outcome for a tooth, but can reduce inflammation sufficiently for
pulpal extirpation to be carried out. Ledermix should not be used as a direct pulp cap if the vitality of the tooth is to
be maintained.

Kalzinol (zinc oxide eugenol)


Kalzinol should be used only as a soothing temporary filling in cases of reversible pulpitis. It should not be used as
cavity liner, use Fuji liner instead.

H-14

Restorative Clinical Procedures


Guidelines for root canal treatment (RCT) ............................................................................................................ I-2
Preoperative considerations .............................................................................................................................. I-2
Single visit / multi-visit........................................................................................................................................ I-2
Materials and equipment ................................................................................................................................... I-3
Preoperative assessment.................................................................................................................................... I-4
Rubber dam ........................................................................................................................................................ I-4
Irrigation ............................................................................................................................................................. I-4
Recapitulation ..................................................................................................................................................... I-4
Endodontic radiography ..................................................................................................................................... I-5
Working length determination ........................................................................................................................... I-5
Working length radiograph................................................................................................................................. I-6
Root morphology ................................................................................................................................................ I-6

Access ..................................................................................................................................................................... I-8


Anterior teeth - Maxillary and mandibular ......................................................................................................... I-8
Premolars - Maxillary and mandibular ............................................................................................................... I-8
Molars - Maxillary ............................................................................................................................................... I-9
Molars - Mandibular ........................................................................................................................................... I-9

Root canal cleaning and shaping ..................................................................................................................... I-10


Modified double flared technique .................................................................................................................... I-10
ProTaper hand file techinque ........................................................................................................................... I-11
Rotary endodontics - ProTaper techique.......................................................................................................... I-12
Preparation of curved canals using ProTaper files ........................................................................................... I-13

Root canal obturation ........................................................................................................................................ I-13


Obturation ........................................................................................................................................................ I-13
Inter-appointment medication and temporisation of access cavity........................................................................... I-13
Endodontic retreatment ............................................................................................................................................ I-14
Problems arising during endodontic treatment ........................................................................................................ I-14
Hypochlorite ..................................................................................................................................................... I-14
Perforation ........................................................................................................................................................ I-14

I-1

Guidelines for root canal treatment (RCT)


The principles of effective root canal treatment remain as we always knew them to be: clean, shape, fill. However,
the emphasis has changed towards a more biological approach, with a greater appreciation of the bacterial nature of
the disease process and a better understanding of factors affecting outcome. Success is not achieved through
obsession with the length of root filling as it appears on a radiograph. It is more dependent on thorough cleaning
and shaping of the canal system and provision of a good coronal seal. Success can be defined as absence of pain and
clinical signs of disease and evidence of peri-radicular health.
We currently teach undergraduates a modified crown down, chemo-mechanical preparation method with a cold
lateral condensation obturation technique. The endodontic teaching is divided between Clinical Skills A, Clinical
Skills B, and Complex Adult Dentistry as shown below:

Year 2

Year 3

Year 4

Clinical Skills A

Clinical Skills B

Complex Adult
Dentistry

Single-Rooted
Endodontics

Multi-Rooted
Endodontics

Advanced
Endodontics

Modified
Double-Flare

Hand ProTaper

Circumferential
Filing

Rotary ProTaper
Endodontic
retreatment

Balanced Force
Technique
Increasing complexity

Preoperative considerations
Once a correct diagnosis has been made and it has been decided that root canal treatment is the treatment of
choice, the considerations / information students should reflect on are:

Single visit / multi-visit


The major restrictions on single visit treatment relate to the time it takes, especially in inexperienced hands. Whilst
it may be convenient to stop after the preparation phase, there are few real contra-indications to single-visit
obturation, particularly for single-rooted teeth. It is wise not to obturate a canal which is persistently wet or one
which demonstrates a symptomless periapical area as the facultative anaerobes which lurk there may put on an ATP
burst, resulting in spectacular abscess formation. The ideal situation would be the vital or partially vital extirpation.
The presence of a sinus is not always a contra-indication to single visit treatment if the canal can be sufficiently
dried. Calcium hydroxide has also been shown to weaken the dentine if left for too long.

I-2

Materials and equipment


Armamentarium available for RCT and respective locations within the clinics are listed below. Due to the individuality
of each case it is hard to divide the materials required for different stages of treatment. Therefore, students should
know the indications for each material / equipment and to be able to anticipate which will be required for patient
treatment.
= Dispensary, = Blue trolley, = In surgery.
Equipment

Endo kit

Burs

High speed:

Files*

Rubber dam kit

EndoZ

K-flex

Rubber dam (latex

No.7 diamond bur

Hedstrom

No.2 shoulder bur (if not

Protaper hand

Butterfly clamp

possible to reach pulp

Protaper rotary

Floss

chamber with no.7)

Protaper

free also available)

OraSeal putty

Finishing diamond burs

Monoject syringe

Slow speed:

Apex locator

Gates Glidden

Finger spreaders

No.1 round bur

Fuji gun

No.2 round bur

Loupes

No.4 round bur

Microscope

Goose-necked burs

retreatment

Articulating paper
Irrigants

Hypochlorite 1%

Lubricants

File-Eze

Inter-visit
medicaments

Chlorhexidine 2%
Povidone Iodine 1%
Fuji Triage (Pink)

Gutta

GP

restorative

ChemFil Rock

percha

Pro-taper matched

Contrast white

setting Ca(OH)2 )
Ledermix

Temporary
materials

Hypocal (non-

and paper
points

points

Cements

TubliSeal

GP solvents

Endosolv E

GP Accessory points

*Files: We have K-flex files, which are of conventional stainless steel structure. The design of the shank allows a little
more flexibility than conventional K-files. Headstron files should be used with care as over-usage may lead to strip
perforations.

I-3

Preoperative assessment
Obtain a parallel, pre-operative radiographic view of the whole tooth, plus 3mm of surrounding periapical bone.
Radiograph visualisation is available through INFINITT software.
The tooth must be considered restorable and with the ability of obtaining a sufficient coronal seal therefore all
caries must be removed and the tooth adequately restored before endodontics can begin.

Rubber dam
Rubber dam is MANDATORY. It is not good enough to simply apply floss or parachute chains to files, rubber
dam MUST be used. If it is not possible to do so, either restore the tooth temporarily e.g. with an amalgam core or
orthodontic band filled with cement or re-consider the initial decision (extraction may be a better option). The dam
must be sealed around the tooth with OraSeal.

Irrigation
The dispensary provides 1% hypochlorite solution and 2% chlorhexidine as irrigants. The student must receive a staff
signature before obtaining the hypochlorite. This is to address the few serious incidents that have occurred using
hypochlorite on the clinics.
The member of staff signing approval must:

Check the rubber dam for integrity.


Check that the student is actually working within the canals!
Check the tooth for open apices, perforations or external resorption.
Check the student has a nurse working with them at all times.
Check that the student is aware of the dangers of using hypochlorite.
o Soft tissue exposure.
o Patient's skin and clothing.
Always use a side vented needle.
Always keep the needle loose within the canal.
Never force hypochlorite into the tooth.

Our protocol for irrigation is:

Use hypochlorite as the sole irrigant during canal preparation.


After preparation is complete, rinse the canal with saline or distilled water.
Final rinse with chlorhexidine.

Hypochlorite and chlorhexidine should never be allowed to mix in the canal as a hazardous precipitate has been
identified. Always make sure the canal is adequately rinsed with saline after using one before using the other.
Povidone iodine 1% is also available for use in cases where the canal is persistently infected.

Recapitulation
Failure to recapitulate will result in canal blockage, this is difficult to clear and attempts to do so may result in ledge
formation or perforation. Therefore canal patency must be maintained at all times. This is accomplished by irrigating
and then returning to the full working length with a smaller file (usually K 15) after each successively larger file.
I-4

Endodontic radiography
Students are encouraged to take their own radiographs during endodontic treatment using the x-ray facilities on the
North and South clinics.
Prior to taking any radiograph the proposed view should be prescribed on the
radiograph request form and signed as approved by the supervising member of staff.
Log on INFINITT software to visualise radiographs taken, there are some useful tools
on the left hand side menu such as 'Measure 2D line' (provide measurement from a
determined point to another) or 'Sharpen filter' (improve diagnostic value of slightly
blurred images) for example. If necessary other tools may be used and at any point
you are able to reset to the original format by pressing 'Reset'.
Which radiographs are required?
Figure I1 Some tools available
on INFINITT software.

Students are required to take:


1.
1.
2.
3.

Pre-operative.
Working length.
Master cone.
Final obturation.

Apex locators may be used in conjunction with working length radiographs or instead only if there is difficulty in
taking the radiograph or viewing the apical area.
If a patient needs to go to the Radiography department for their radiograph, they should not be asked to sit in the
waiting room with rubber dam and files in place. The student should go there alone first to inform the staff that an
endodontic patient is needing to be seen, when the staff are ready to accept the patient the student should return
to fetch the patient who can be taken straight though the radiography waiting room.

Working length determination


Working length should be estimated from the preoperative radiograph (use 'ruler' tool on INFINITT software) and
then determined using an apex locator. For most cases a working length radiograph is useful to confirm the findings.
If an apex locator is not available refer to 'Working length radiograph' further bellow.
Apex locators are available from dispensary. There are several different systems available but all have the following
common features:

There is an electrode to clip on the patient's lip.


The file that is attached to the other electrode should not be in contact
with any metal objects such as the rubber dam clamp or amalgam
restoration.
The reading should go to '0', between green and red readings (green
means file still away from apical constriction, red means file went
through the apical constriction) and then subtract 0.5mm for the most
accurate results, determining the working length.

I-5

Figure I2 - Rapex 5 apex locator.

Working length radiograph


Take a diagnostic radiograph using the first file which feels tight at the working length (the 'diagnostic file'). This
radiograph should be taken using an 'Endo-ray' film holder (available from dispensary) and fulfil the criteria
established for the pre-operative radiograph. Details of the diagnostic file (length, coronal reference point, size)
should be recorded in the patient's notes.
If an apex locator is not available, working length (WL) should be determined by subtracting 2mm from the
Radiographic length (assessed on preoperative radiograph), then taking a diagnostic radiograph and calculating the
difference from the radiographic apex to the tip of the diagnostic file in a manner that the WL will be 1mm short
from the radiographic apex e.g. diagnostic file has extruded by 1mm, thus 2mm should be reduced from the WL. If
unsure this could be re-assessed by taking a further diagnostic radiograph.

Root morphology
Knowing the average number of canals and average length values of each tooth can be helpful, especially to the
more inexperienced students. This information will aid on decision to look further for other canals and to assess if
provisional working length are in accordance to average measurements (from Ingles Endodontics 2008).
Maxillary tooth

Canals

Average Length

Central Incisor

1 canal -100%

23.3 mm

Lateral Incisor

1 canal - 99.9%

22.8 mm

Canine

1 canal - 100%

26 mm

2 canals and 2 foramina - 72%


First Premolar

2 canals and 1 foramen - 13%

21.8 mm

1 canal and 1 foramen - 9%


3 canals and 3 foramina - 6%
1 canal and 1 foramen - 75%

Second Premolar

2 canals and 2 foramina - 24%

21 mm

3 canals - 1%

First Molar

In tooth:

In MB root:

4 canals - 56.5%

1 canal and 1 foramen -41.1%

3 canals - 41.1%

2 canals and 1 foramen - 40%

5 canals - 2.4%

2 canals and 2 foramina - 18.9%

In tooth:
Second Molar

3 canals - 54%
2 canals - 46%

In MB root:
1 canal and 1 foramen - 63%
2 canals and 1 foramen - 13%
2 canals and 2 foramina - 24%

I-6

MB - 19.9 mm
DB - 19.4 mm
P - 20.6 mm
MB - 20.2 mm
DB - 19.4 mm
P - 20.8 mm

Mandibular tooth

Canals

Average Length

1 canal - 70.1%
Central Incisor

2 canals and 1 foramen - 23.4%

21.5 mm

2 canals and 2 foramina - 6.5%


1 canal - 56.9%
Lateral Incisor

2 canals and 2 foramina - 29.4%

22.4 mm

2 canals and 1 foramen - 14.7%


Canine

1 canal - 94%

25.2 mm

2 canals and 2 foramina - 6%


1 canal and 1 foramen - 73.5%

First Premolar

2* canals and 2 foramina - 19.5%

22.1 mm

2* canals and 1 foramen - 6.5%


3 - 0.5%
1 canal and 1 foramen - 85.5%

Second Premolar

2* canals and 2 foramina - 11.5%

21.4 mm

2* canals and 1 foramen - 1.5%


3 canals - 0.5%
In M root:

First Molar

2 canals and 1 foramen - 40.5%


2 canals and 2 foramina - 59.5%

Second Molar

In D root:
1 canal and 1 foramen - 71.1%

M - 20.9 mm

2 canals and 1 foramen - 17.8%

D - 20.9 mm

2 canals and 2 foramina - 11.1%

In M root:

In D root:

1 canal and 1 foramen - 13%

1 canal and 1 foramen - 92%

M - 20.9 mm

2 canals and 1 foramen - 49%

2 canals and 1 foramen - 5%

D - 20.8 mm

2 canals and 2 foramina -38%

2 canals and 2 foramina - 3%

*Incidence is higher in black persons than in white persons.

I-7

Access
Loupes and microscopes are available for use. The student should know the necessary anatomical reference points
and access cavity outline before beginning. Bear in mind the objective of the access cavity: to create a smooth,
straight line access to the canal system. Damage to the pulpal floor can be avoided by using non-cutting end burs
(endo-Z).

Anterior teeth - Maxillary and mandibular


1.

2.
3.
4.
5.
6.

Initial penetration is made in the exact centre of the palatal surface, this should be initially done with a high
speed diamond bur at a right angle to the long axis of the tooth (only in enamel). Then bur should be brought
toward the incisal (bur is now parallel to long axis of tooth).
Once the 'drop' into the pulp chamber is felt, change to the endo-Z bur and increase the convenience extension
toward the incisal.
Use slow speed round burs and work from inside of the chamber to outside to remove the lingual and labial
remnants of the pulpal roof as well as to eliminate pulpal horn debris and bacteria.
Remove the lingual shoulder working from inside out with the endo-Z bur.
The resulting cavity should be continuous and flowing from cavity margin to canal orifice.
Final shape relates to internal anatomy of pulp chamber and canal, in young adults (tooth with large pulp) the
shape is a large triangle, in older adults (chamber obturated with secondary dentin) access is ovoid in shape.

Figure I3 - Mandibular anterior teeth access cavity design.

Figure I4 - Maxillary anterior teeth access cavity design.

Premolars - Maxillary and mandibular


1.
2.
3.

4.
5.

Initial penetration is made with a high speed diamond bur in the exact centre of the central groove. Bur is
parallel to long axis of tooth.
Once the 'drop' into the pulp chamber is felt, change to the endo-Z bur and enlarge bucco-lingually to twice the
width of the bur for exploration.
Locate with endodontic explorer the buccal and lingual canals in the first premolar and the central canal on the
second premolar (tension of explorer against the walls of preparation indicates the amount and direction of
extension necessary, so remove further tissue with endo-Z).
Use from inside to outside a round slow speed bur to ensure complete removal of the roof of the pulp chamber.
Final ovoid preparation is tapered funnel from the occlusal to the canal.
I-8

Figure I5 - Maxillary posterior teeth access cavity design.

Figure I6 - Mandibular posterior teeth access cavity design.

Molars - Maxillary
1.
2.
3.
4.
5.
6.

Initial penetration is made with a high speed diamond bur in the exact centre of the mesial pit, with the bur
directed toward the lingual.
Once the 'drop' into the pulp chamber is felt, change to the endo-Z bur and enlarge this for exploration.
Locate with the endodontic explorer orifices of MB, DB and P canals (tension of explorer against the walls of
preparation indicates the amount and direction of extension necessary, so remove further tissue with endo-Z).
Use from inside to outside a round slow speed bur to ensure complete removal of the roof of the pulp chamber.
Final finish is obtained with the endo-Z bur. explore carefully the presence of a 2nd Mesio-buccal canal.
The cavity is entirely within the mesial half of the tooth. Access shape is triangular, the base is toward the buccal
and apex is to the palatal.

Molars - Mandibular
1.
2.
3.
4.
5.

Initial penetration is made with a high speed diamond bur in the exact centre of the mesial pit, with the bur
directed toward the distal.
Once the 'drop' into the pulp chamber is felt, change to the endo-Z bur and enlarge this for exploration.
Locate with endodontic explorer orifices of MB, ML and D canals (tension of explorer against the walls of
preparation indicates the amount and direction of extension necessary, so remove further tissue with endo-Z).
Use from inside to outside a round slow speed bur to ensure complete removal of the roof of the pulp chamber.
Final prep extends to the height of mesial cusps, explore carefully the presence of a 2nd distal canal, if this is the
case, the access will be square in shape; otherwise if 3 canals are present access shape is more triangular, with
its base toward the mesial side of the tooth.
I-9

Root canal cleaning and shaping


Modified double flared technique

Coronal
preparation

Create coronal access (flare) in the coronal half to two-thirds (or straight portion in a
posterior tooth) of the canal(s) with sizes 15, 20 and 25 files, followed by Gates Glidden
burs nos. 4, 3 and 2 (used successively more deeply), irrigating between each instrument
change.

Take the working length radiograph.

Apical third
preparation

Prepare the apical portion of the canal system using a circumferential filing action with the
diagnostic file and two sizes larger than it (minimum size 25). The last file used at the full
length is the 'master apical file' (coronal reference point, length and file size must be
recorded in the patient's notes).
Keep irrigating between each instrument change.
Step-back in millimetre increments, using at least three or four files, each successively
larger than the master apical file, recapitulating to the full length with the master apical file
after each new file is used.

Figure I7 Modified double flared technique diagram.

I-10

ProTaper hand file technique


1

Tutor signs notes to indicate they are happy for ProTaper to be used.

Coronal Flare with


SX Orifice shaper:

SX

Working length determination and glide path preparation up to size 20 before getting ProTaper
shaping & finishing files.
Recapitulation and irrigation between files is of utmost importance.

S1

S2

Once glide path


preparation is
complete,
ProTaper shaping
and finishing files
can be used to
complete
preparation.

F1

F2

F3

I-11

Rotary endodontics - ProTaper technique


Students are taught rotary endodontic techniques in year 4. They should show
evidence of successful hand endodontics before being allowed to use the rotary
system.
We use the Pro-taper universal system. X-smart motors and files are available
from dispensary.

Figure I8 - X-Smart motor.

Safe usage
Do

Do not

Force instruments into canal.


Instrument should never be
held at the same point.
Use rotary instruments
unless you have explored the
canal first with k-files.

Suggest use 200 rpm.


Torque setting according to file.
Use a lubricant such as File-Eze (EDTA).
Start motor before placing instrument into canal.
Gently introduce file into canal until light resistance is felt and withdraw.
Files should be used in an in and out motion (touch / retract / touch / retract),
no more than 1mm at a time and/or limiting the file work to 4 seconds for each
time.
Remove all debris from instrument.
Recapitulate and irrigate as usual.
The sequence is repeated until reaching the full working length.

Protocol
Stage
1

Scout Canal

Files

Torque

K 15
K 20
S1

Technique

Until light resistance felt

Passive watch winding

Distance reached by size 20 Kfile

Brushing motion

Coronal Flare

Working Length

K 15

Full working length

Balanced force

Glide Path

K 20

Full working length

Balanced force

Full working length

Brushing motion

Full working length

Non-brushing motion

Coronal Shaping

Apical Finishing

SX

Working to

S1

S2

1.5

F1

F2
F3

I-12

Preparation of curved canals using ProTaper files


Nickel Titanium files such as ProTaper are prone to fracture, particularly when driven in a rotary handpiece.
1.
2.
3.
4.
5.

Following access cavity preparation, coronal flare may be performed using gates glidden burs as described
previously, or alternatively using the SX orifice shaper from the ProTaper series.
Working length should be determined using a radiograph as described previously.
'Glide Path' preparation using k-files at the full working length up to a size 25.
Initial shaping of the canal using S1 and S2 shaping files. The full working length must be reached with the S2
file before progressing onto the finishing files.
Finishing of the apical preparation using F1 and F2 finishing files. F3 should only be used in large, relatively
straight canals.

The preparation is complete when the canal system has been cleaned and shaped so that it may be filled effectively.
Any curvature should have been maintained, the preparation should produce a smoothly tapered form and its length
should be maintained at that determined from the diagnostic radiograph.

ROOT CANAL OBTURATION


Obturation
1.
2.
3.

The tooth must be sign and symptom free.


The canal must be able to be dried, use paper points for this.
Use a GP point matched to the master apical file. If GP point does not bind at the full length ('tugback'),
remove a little from the tip or select a larger point until 'tugback' at the correct length is felt.
4. Take a radiograph to ensure the point is in the correct position (master point radiograph).
5. If the radiograph is adequate, cement master point in place with Tubliseal cement.
6. Seal the canal system using cold lateral condensation with finger spreaders, multiple accessory gutta percha
points and Tubliseal cement. Ensure the spreader will fit to within 1 mm of the full working length before
obturation.
7. Remove excess gutta percha, far down in to the access cavity at the CEJ level on incisors, canines, pre-molars
and at the canal orifice level for molars, using a hot instrument from the endo kit NOT from the cavity prep
kit. A Safe Air heater or induction heater can be used to heat the instrument.
8. Take a final radiograph to check the obturation.
9. Provide a definitive coronal restoration. The importance of the coronal seal is central to long-term success
(see 'restoration of the root-filled tooth').
10. Monitor success clinically and radiographically.

Inter-appointment medication and temporisation of access cavity


Non-setting calcium hydroxide (Hypocal) has a pH around 12, is anti-bacterial and
proteolytic. It is the inter-visit medicament of choice and will act as a temporary
obturation material. Ledermix should ONLY be used if pulp extirpation (in case of
irreversible pulpitis) is not possible.
Conventional GIC (Fuji Triage (Pink), ChemFil Rock Contrast white) should be used to
seal the access cavity. Don't forget to place cotton pellets over the canal entrances
before placing GIC and to check the occlusion after the cement has set completely.
I-13

Figure I9 - RCT temporisation


diagram.

Endodontic retreatment
A common requirement nowadays. Removing old gutta percha can be assisted by Gates Glidden burs and use of a
solvent (Endosolv E is available at dispensary) to ease passage of hand files. ProTaper retreatment files and
Hedstrom files are also available for these cases, caution must taken be with the latter as over use might create strip
perforations.
Before using a solvent it is worth trying to 'screw' a small size Headstrom file through the GP down to around 2/3 of
the obturation length and if this was not particularly well condensed you might remove the whole obturation when
pulling the file out.
Students are encouraged to take a radiograph to determine complete removal of the existing GP before beginning
re-preparation.

Problems arising during endodontic treatment


Hypochlorite
If Hypochlorite is inadvertently injected into the soft tissues the patient is likely to suffer serious and extremely
painful consequences. Prevention is the best management so therefore always measure how far the irrigating
needle is going into the tooth, check that it is side vented and keep it loose at all times whilst irrigating. Student
using hypochlorite must have an assistant using high volume suction to quickly remove excess as it flows out of the
tooth.
If the patient should suffer an incident the following approach should be adopted:

Explain to the patient what has happened.


Try to flush out the hypochlorite with saline.
Allow the tooth to bleed.
Dry up as much as possible with paper points.
Dress the access cavity with no intracanal dressing.
Prescribe anti-inflammatory drugs.
If the patient is at risk, also prescribe antibiotics.

Follow up within 24 hours.


In serious cases there can be long term nerve damage and patients not responding to simple measures must be
referred immediately to casualty for anti-inflammatory and steroid treatment and also receive a neurological
examination.

Perforation
Try to assess the position and size of the perforation. If near the surface (accessible) perforations should be covered
with Biodentine. Larger perforations may be treated with MTA or Biodentine and may need a surgical approach, the
supervisor should consult the covering consultant before attempting management of such cases.

I-14

Restorative Clinical Procedures


Guidelines for the restoration of root filled teeth ...............................................................................................J-1
The ferrule ...............................................................................................................................................................J-1
Posts.........................................................................................................................................................................J-2
Core build-ups .........................................................................................................................................................J-2
The need for crowns ...............................................................................................................................................J-2
Summary for anterior teeth ....................................................................................................................................J-2
Summary for posterior teeth ..................................................................................................................................J-2
Nayyar core technique - Step-by-step guide ..........................................................................................................J-3
Prefabricated fibre post and core - Step-by-step guide.........................................................................................J-4

Guidelines for the restoration of root filled teeth

GP should be removed back to a level equivalent to the level of the CEJ and sealed off with RMGIC lining
material.
Posts should only be used if there is insufficient remaining tooth tissue to retain a core. Usually sufficient
retention can be obtained if 2-4 mm of coronal GP is removed from canals (Nayyar technique).
Adhesive fibre posts are preferred to metal posts as they have a similar flexural modulus to dentine and
failure is more treatable than if metal posts fail.
Prefabricated posts are preferred to cast posts as they avoid the need for temporization frequently
associated with leakage.

The ferrule

Ferrules increase the fracture resistance.


1.5 to 2mm required.
Don't crown lengthen to achieve this as the root becomes
narrower, the benefit of the ferrule is countered by
significant weakening of the root.
Partial ferrule better
than none.

Figure J1 - Ferrule of 1.5 - 2mm increases fracture resistance.

J-1

Posts
Posts should only be used in last ditch circumstances. Their use does not improve the outcome of endodontics and
weakens the root.
Fibre paraposts are available in 3 different widths. The wider the post the stronger it will be at the expense of the
strength of the root. The narrowest post should be tried in first, if it has insufficient stability then and only then
move up in size. The burs for preparing the post hole are in the endodontic kits and are colour matched to the posts.

Core build-ups
When using prefabricated posts, composite cores can be constructed either anteriorly or posteriorly and amalgam
posteriorly. Glass ionomer cements and cermets (Ketac) are not strong enough to resist the tensile forces.
If composite is used as a core material, any impressions should be delayed for 1 week following placement. This will
allow hygroscopic expansion to occur before preparation rather than during the period that the crown is being
constructed.

The need for crowns


For anterior teeth, the need for a crown must be made on aesthetic need only, there is no evidence that crown
placement following RCT improves the outcome.
For posterior teeth there is very strong evidence that cuspal protection following RCT has major impact on the
success rates of endodontics, in general, crowns or onlays should be used in all cases unless the stress on the tooth is
considered very low.

Summary for anterior teeth


Access cavity only

Composite restoration only


Bleach / veneer only for aesthetics

Fractured above gingival level

If can get a ferrule use adhesive techniques for core and crown

Fractured at gingival level

Adhesive fibre post / Composite core + crown

Fractured below gingival level

Electrosurgery to expose margins, fibre post, composite core and crown


Or
Gold post with diaphragm

Summary for posterior teeth


Low stress

High stress

Small Class I

Direct composite or amalgam

Composite core + onlay / crown

Class II

Direct composite or amalgam

Composite core + onlay / crown

Cusp(s) missing with > residual

Nayyar core + direct composite /

Nayyar bonded amalgam core + crown

tooth height remaining

bonded amalgam

Cusp(s) missing with < residual

Premolar Fibre post + bonded composite core + crown

tooth height remaining

Molar Nayyar bonded amalgam core + crown


J-2

Nayyar core technique - Step-by-step guide


Tooth recently obturated.
1. GP taken down to level of
root canal orifices.

2. Using Gates Glidden


remove 2-4 mm of GP
from each canal.
The size of the GG depends
on the amount of coronal
flare.
The canal should not be
widened significantly just
cleaned of GP.

3. GP and dentine lined with


RMGIC (Fuji Lining).
Avoid getting liner onto
enamel.
Apply with thymosin probe
and wipe canal orifices out
with paper point to avoid
pooling.
Thin layer only required.

4. Pack amalgam firstly


into roots with perio
probe or endodontic
condenser.
5. Build up core.

J-3

Prefabricated fibre post and core technique - Step-by-step guide


This technique is used to aid retention for the core of the crown if very little coronal tissue is remaining.

1. Use GG burs in order to


remove GP follow canal
direction to desired length.

2. Use Parapost drills to prepare post channel.


Try in matching fibre post, ensure stability and fit to
desired length (may need to move up drill size be
aware of canal / root width).

3. When post fits, may


need to cut post to desired
length (cut from flat end).
Prepare Nayyar preps in
other obturated canals.

4. Wash.

5. Dry with paper points.

6. Activate and mix cement


capsule and inject cement
into canal.

7. Insert post and remove


coloured rubber band
when set.

8. RMGIC liner over GP and


dentine of pulp chamber.

9. Etch and bond with


Optibond if restoring with
composite core.

10. Build up composite


core.

11. Prefabricated post and


core.

J-4

Restorative Clinical Procedures


Crowns and extra-coronal restorations ................................................................................................................ K-2
Prescription ............................................................................................................................................................ K-2
Preparation adequacy ............................................................................................................................................ K-2
Crown margin positioning...................................................................................................................................... K-2
Crown lengthening ................................................................................................................................................. K-2
Study casts and articulators ................................................................................................................................... K-2
Multiple crown cases ............................................................................................................................................. K-2

Temporary crowns............................................................................................................................................... K-3


Temporary crown cementation ......................................................................................................................... K-3

Types of Crowns ................................................................................................................................................... K-3


Anterior .............................................................................................................................................................. K-3
Dentine bonded crowns .............................................................................................................................. K-3
Metal ceramic crowns (MCC) ...................................................................................................................... K-4
Posterior ............................................................................................................................................................ K-5
Partial veneer crowns .................................................................................................................................. K-5
Full gold (full veneer crowns - FVC) ............................................................................................................. K-5
Metal ceramic crowns (MCC) ...................................................................................................................... K-6

Impressions........................................................................................................................................................... K-8
Gingival tissue management for impressions.................................................................................................... K-8
Custom vs. stock trays ....................................................................................................................................... K-8
Impression Materials ......................................................................................................................................... K-8
Adequacy of impressions.............................................................................................................................. K-8
Occlusal registrations and opposing arch impressions...................................................................................... K-8
Ceramic shades....................................................................................................................................................... K-9
Trial fitting of crowns ............................................................................................................................................. K-9
Occlusal checking ................................................................................................................................................... K-9
Management of a 'high' crown ........................................................................................................................ K-10

Cementation ....................................................................................................................................................... K-10


Zinc phosphate ................................................................................................................................................ K-10
Resin composite............................................................................................................................................... K-10
Resin modified glass ionomer .......................................................................................................................... K-10

Follow up - Review ............................................................................................................................................ K-10


K-1

Crowns and extra-coronal restorations


Prescription
The students should try to gain breadth of experience and to undertake examples of as wide a range of different
crown types as possible. However they must recognise that all crowns are destructive and most require removal of
large amounts of sound tooth substance. They should therefore be encouraged to explore fully any less invasive
options (e.g. composite build ups, intra coronal restorations or veneers) as part of the diagnostic and prescriptive
process.

Preparation adequacy
Students should be encouraged to think carefully before starting a crown prep. about the criteria which contribute
towards a successful preparation (e.g. degree of taper, occlusal reduction, marginal clarity, marginal position,
clearance of contacts, retentive length of preparation, need for grooves / slots etc.) with a view to being
constructively critical of their own work and evaluating their achievement against the predetermined criteria.
Varying degrees of staff guidance will be required depending on the level of experience and ability of the individual
student.
Students are encouraged to use sectioned putty indices to help self assessment.

Crown margin positioning


Where possible, for ease of inspection and oral hygiene maintenance, crown margins should be placed
supragingivally, except in areas where aesthetic considerations require extension into the gingival crevice. In such
cases over extension and disruption of the periodontal tissues at the base of the crevice must be avoided. Where
possible crown margins should however, finish on sound tooth structure and not on restorations.

Crown lengthening
Crown lengthening can be carried out by the supervising member of staff using the diathermy equipment available.

Study casts and articulators


Study casts and diagnostic waxing can be arranged and should be used where considered clinically appropriate to
support diagnostic and treatment planning procedures for more complex cases. They are not considered essential in
simpler cases but should be used in any cases where the inter arch relationship or the vertical dimension is to be
changed.
The Denar II semi-adjustable articulator system is available with the Slidematic facebow for crown and bridgework
and students are trained in their use in the CSB course in their Third year. Single crowns in bounded sites will not
normally require use of semi-adjustable articulators but they should be considered for crowns on last standing teeth
in the arch, teeth carrying occlusal guidance (e.g. canines or incisors) and multiple crown cases (3) or teeth in group
function.

Multiple crown cases


It would be helpful if cases involving in excess of 4 crowns could be drawn to the attention of a senior member of
restorative staff to approve the treatment planning.

K-2

Temporary crowns
Students should plan temporisation (including the potential use of study casts and diagnostic wax ups) before
commencing crown preparation.
Temporary crowns should be constructed prior to impression taking in case of time shortfalls. More junior students
may be better deferring the impression stage to the second visit may be prudent to avoid over lengthy visits for
patient or student alike.
Both Replication and Proprietary temporary crown systems are taught. Directa temporary crowns for both anterior
and premolars are available. With ISO Form preformed aluminium molar and premolar temporary crowns for
posterior teeth. Directa and Aluminium temporary crowns will require appropriate addition of a cold cure acrylic
(Trim) or temporary crown and bridge material (Integrity) to improve the fit prior to cementation.
Where study casts are not available, localised silicone putty indices should be recorded in advance of preparation for
customised temporary techniques and should include at least one tooth on either side of that which is to be
prepared. Trim and Integrity are available as customising temporary crown materials.
A good temporary crown should have good, cleansable margins, appropriate occlusion and contact points.

Temporary crown cementation


Temp Bond (eugenol containing) and Temp Bond NE (non eugenol - for use with glass ionomer and composite
containing cores) are available. Modifier is available if permanent crowns are to be cemented temporarily.

Types of Crowns
Anterior
Dentine bonded crowns
These have superseded Porcelain Jacket Crowns (PJC's)
unless previous PJC's are being replaced, like with like.
Similar to veneer preparations, the dentine bonded crown
preparation is minimal. The resulting crown is weak until
cemented.
The preparation has a chamfered margin on all aspects and
is similar to that which might result from the preparation of
an anterior tooth for a full veneer gold crown. The
preparation should comprise mainly sound tooth tissue
(enamel and dentine) with a limited proportion of
Figure K1 - UL2 completed dentine bonded crown prep.
composite resin or glass ionomer build up being acceptable.
This type of crown is cemented using a resin luting system similar to that which would be used for ceramic veneers).
Criteria for preparation:

Incisal reduction (1.5 - 2mm).


Well defined recordable margins (chamfer):
o Buccal / labial reduction (0.5 - 0.7mm), least in cervical region, follow anatomical form.
o Palatal reduction (0.5 - 0.7mm), follow anatomical form.
K-3

Interproximal reduction.
10 - 15 taper.
Supragingival margins (0.5mm) if possible (consider aesthetic issues).
No undercuts.
Smooth surface finish.
No iatrogenic damage to adjacent teeth.

Metal ceramic crowns (MCC)


Metal ceramic, full coverage - these offer strength and aesthetics plus the ability to integrate with multi unit bridge
designs but are destructive and invasive preparations especially on vital teeth.
Features of the preparation:

Criteria for preparation:

Adequate incisal reduction (2mm), sloping towards palatal.


Well defined recordable margins:
o Buccal shoulder (1.2 - 1.5mm).
o Palatal / lingual chamfer (0.5mm).
1.2 1.5 mm labial / buccal reduction in 2 planes, follow anatomical form.
0.5 0.7 mm palatal reduction for metal, follow anatomical form.
Interproximal reduction.
8 - 12 taper.
No undercuts.
Finishing of preparation removal of sharp edges.
No iatrogenic damage to adjacent teeth.
K-4

Posterior
For posterior teeth there are three essential options for full veneer crowns and also partial veneer crowns are
available.
For full veneer crowns the choice lies between full gold, metal ceramic and all ceramic.
All ceramic crowns are highly destructive and very expensive. They are outsourced from our laboratories and only
should be considered in the most demanding of cases. Approval for prescribing an all ceramic crown must be gained
from a consultant.
Metal ceramic crowns with ceramic occlusal surfaces or posterior all ceramic crowns (not usually indicated due to its
destructive nature) can be problematical for patients with bruxism and erosive tooth wear due to the abrasivity of
the porcelain, for patients with canine guidance this shouldn't be a problem. Otherwise, explain to the patient that
metal occlusal surfaces or full gold crows are more appropriate in these situations.

Partial veneer crowns


The students are no longer taught the procedures for partial veneer crowns in the laboratory courses, they may be
prescribed, but careful supervision will be required.

Full gold (full veneer crowns - FVC)


Gold crowns are the most conservative full veneer crown for posterior teeth and should be offered as the first option
in most cases, especially bruxists and patients with tooth wear.
Even though this design is called a full gold crown, our laboratory produces this in cobalt chrome metal (silver
colour).

Figure K2 - UR6 completed FVC prep.

K-5

Criteria for preparation:

Occlusal reduction 1mm maintaining anatomical morphology.


o 1.5mm in the region of the functional cusp (functional cusp bevel).
Well defined recordable margins:
o Supragingival where possible.
o 0.5 mm chamfer margin.
Buccal and lingual axial reduction with chamfer bur (0.5mm).
Proximal reduction (0.5mm chamfer).
12 taper.
No undercuts.
Smooth surface finish.
No iatrogenic damage.

Metal ceramic crowns (MCC)


The students are taught to first carry out a full gold preparation and add in the shoulder afterwards, in this way
wings are created which add to retention and resistance and make for a more conservative preparation.

Figure K3 - MCC prep on an UR4.

Criteria for adequate preparation:

Adequate occlusal clearance, maintaining anatomical morphology:


o If metal occusal surface: 1mm non-functional cusp.
1.5mm functional cusp bevel.
o If porcelain occlusal surface: 2mm non-functional cusp.
2.5mm functional cusp bevel.
Well defined recordable margins:
K-6

o Buccal shoulder (1.2 - 1.5mm).


o Palatal / lingual chamfer (0.5mm).
Interproximal reduction.
Adequate labial / buccal reduction for metal and porcelain.
Adequate palatal reduction for metal.
No undercuts.
Finishing of preparation.
No iatrogenic damage to adjacent teeth.

Occlusal and marginal variations:


The choice of porcelain or metal occlusal surface must be indicated on the laboratory prescription and is determined
by:
Aesthetic need.
Sufficiency of crown height.
Occlusal factors such as bruxism.
The variations the students learn are:
Metal only, porcelain on buccal cusps only and porcelain across the whole occlusal surface
Where the decision is made to have porcelain on the occlusal surface sufficient tooth reduction must be carried out
to accommodate this.
Where aesthetics allows, gold margins can be employed as a means of further preserving tooth tissue by creating a
chamfer instead of a shoulder, the technician will wax up a gold substructure and incorporate the porcelain once
there is adequate room available. This is particularly useful recession cases. For the patient there is a visible gold
margin to the crown, but fit and cleansibility are superior.

Figure K4 - Variations in occlusal design.

Figure K5 - Gold collar margins.

K-7

Impressions
Gingival tissue management for impressions
The use of retraction cord is regarded as an essential pre-requisite to
impression taking unless in exceptional circumstances or where all
margins are clearly supragingival. A twin cord technique, with the deeper
layer remaining in situ during impression taking, is preferred with
removal of, and accounting for, the retraction cord being a point which
members of staff should check with particular care. The use of
astringents or haemostatic agents with retraction cord is optional and
serrated cord placement instruments are available separately from
dispensary if required. If epinephrine solution is used, consider especially- patients with heart problems as there are concerns over
'epinephrine syndrome' (raised heart rate, respiratory rate and blood
pressure) when solution is used on lacerated gums in susceptible
patients. Gingival retraction without adequate local analgesia is not
recommended.

Figure K6 - Placement of retraction cord.

Custom vs. stock trays


When required e.g. for 3 or more crowns, custom trays can be ordered from the laboratory. Custom trays are
normally constructed in light cure acrylic with 6mm spacing, occlusal stops on selected non prepared teeth and a
short handle. A range of disposable stock are available from the trolleys on the clinic. For single crowns custom trays
are not required.

Impression materials
A single stage heavy and light bodied addition cured silicone technique is preferred. Heavy bodied materials are
dispensed from the bulk dispensers available in each unit.

Adequacy of impressions
Students are to be encouraged to 'read' their own impressions and to comment constructively on their adequacy or
otherwise, identifying where possible any faults and their possible causes and making a decision as to whether or not
the impression is clinically usable.
All impressions should be disinfected in the bath on the units prior to being sent to the laboratory.

Occlusal registrations and opposing arch impressions


Opposing arch alginate impressions are required. Where the Inter Cuspal Position (ICP) requires recording then a jaw
registration material such as Blu Mousse can be used ( in conjunction with record rims where required). Where there
is a clear ICP and hand held models could be located, then simply Blu Mousse over the preparation to assist location
is all that is required. If recording the retruded contact position Moyco Hard Pink Beauty Wax is the material of
choice. If current study casts are available the opposing arch impression can obviously be omitted. Where multiple
crowns or groups of crowns are being undertaken simultaneously, appropriate locating registrations for articulation
of the working cast will be required.

K-8

Ceramic shades
The Vita ceramic shade guide is used routinely. Students are to be encouraged to decide upon the appropriate shade
and to involve the patient in this process (subject to staff ratification before entering this information on the
laboratory prescription sheet).

Trial fitting of crowns


If temporaries do not yield to conventional removal with an excavator, 'slide-hammer' type crown removers are
available from the dispensary but should not be used unsupervised by all but the most senior final year students.
Students should be encouraged to adopt a critical and analytical approach to assessing the adequacy of their final
restorations. Positive as well as negative feedback is always important to the laboratory staff involved in crown
manufacture. Any deficiencies or inadequacies should be discussed and diagnosis of any clinical or laboratory factors
contributing to failure of a restoration regarded as essential knowledge for both the operator and technician should
be made prior to a remake, therefore avoiding repetition of mistakes.
It is the responsibility of the supervising member of staff to ensure that any crowns not fitted are returned to the
laboratory.

Occlusal checking
Metal crowns may be ordered with matt occlusal surfaces to make intra oral occlusal adjustment easier with the
articulating paper available. Occlusal indicator wax and extra thin articulating paper are routinely available with
shim stock and GHM foil available from dispensary on staff request.

K-9

Management of a 'high' crown

Figure K7 - Flowchart for management of a 'high' crown.

Cementation
Staff approval must be obtained before final cementation of a crown(s). There are a number of luting cements
available:
Zinc phosphate (DeTry Zinc) A traditional cement, useful for cast metal posts and metal crowns with good
retentive features.
Resin Composite (Rely-X Unicem, Rely-X Ultimate and Panavia 2.0) Useful for less retentive preps. Beware that if
the student fails to seat the crown correctly the crown will need to be 'prepped' off.
Resin Modified Glass Ionomer (Fuji Plus) Used for cementation of single metal ceramic or gold crowns and
conventional bridgework.

Follow up - Review
Review of completed items of work is regarded as an essential component of the learning process and students
should be checking previously placed crowns particularly with respect to periodontal health and occlusal harmony.

K-10

Restorative Clinical Procedures


Bridges ........................................................................................................................................................................ L-2
Treatment planning................................................................................................................................................ L-2
Use of articulators .................................................................................................................................................. L-2
Selection of abutment teeth .................................................................................................................................. L-3
Resin bonded bridges (RBB) ............................................................................................................................. L-3
Patient assessment, diagnosis and treatment planning............................................................................... L-3
Indications / contraindications ..................................................................................................................... L-3
Bridge design ................................................................................................................................................ L-3
Framework design ........................................................................................................................................ L-3
Clinical stages ............................................................................................................................................... L-4
Preparation .............................................................................................................................................. L-4
Principles of preparation ......................................................................................................................... L-4
Impressions.............................................................................................................................................. L-4
Try in ........................................................................................................................................................ L-4
Bonding of RBB ........................................................................................................................................ L-5
Conventional bridgework ................................................................................................................................. L-5
Types of bridges ........................................................................................................................................... L-5
Fixed-fixed ............................................................................................................................................... L-5
Fixed-moveable ....................................................................................................................................... L-5
Cantilever................................................................................................................................................. L-5
Spring cantilever ...................................................................................................................................... L-5
Luting agents for conventional bridgework ................................................................................................ L-6

L-1

Bridges
Students are taught the skills of bridge preparation during year three and should not commence any cases until
years 4 and 5.
Before embarking on any form of bridgework, it is important to have a specific reason for replacing the missing
teeth. The following factors should be taken into consideration:

Aesthetics.
Function.
Mastication and speech.
Occlusal Stability.
Comfort.

Treatment planning
A general assessment of the patient's suitability to undergo advanced restorative procedures should be carried out
taking into consideration the patient's general health and ability to undergo the restorative procedures along with
their motivation towards such treatment.
As in all situations of planning complex restorative treatment a full history and examination is required along with
any special tests deemed necessary. These should certainly include vitality tests and radiographs of any potential
abutment teeth. Study casts are of great assistance in assessing occlusal relationships and allowing the provision of a
diagnostic wax-up.
The following local factors should be taken into consideration:

Oral hygiene and periodontal condition.


Number and position of missing teeth.
Length of span.
Occlusion.
Condition of potential abutment teeth.

Patients with poor oral hygiene or active periodontal disease should undergo an intense course of oral hygiene
phase therapy before consideration of bridgework.
In situations with extensive saddles (3 or more missing teeth) or where multiple saddles exist, a removable option
should be considered. Likewise, if extensive bone resorption has occurred, particularly in the anterior part of the
mouth, the use of a flanged removable denture will allow replacement of both the missing teeth and underlying
supporting tissues.

Use of articulators
We would like all students undertaking bridgework to have carried out a facebow recording and have models
mounted on a semi-adjustable articulator as part of the planning process.
If a re-organised occlusal scheme is planned, articulation of the study casts becomes an essential part of treatment
planning. Likewise, in situations where an existing occlusal guidance needs to be reproduced or when a planned
alteration to the guidance is to be introduced, the use of an articulator is mandatory.
L-2

Selection of abutment teeth


Potential abutment teeth should be carefully scrutinised from the apex to the crown. Recent radiographs should be
checked to ensure absence of apical pathology, root morphology and periodontal bone support. Coronal restorations
should be investigated and replaced if any doubt exists as to their integrity or seal.
Root filled teeth should only be considered if there is adequate remaining coronal tissue and the root filling is of high
quality and the tooth symptom free.

Resin bonded bridges (RBB)


The introduction of the resin-bonded bridge has provided a conservative method of replacing missing teeth with a
fixed restoration. The technique produces minimal disturbance to the pulp and periodontal tissues. The main
disadvantage of the design is the potential for debonding.

Patient assessment, diagnosis and treatment planning


Careful and thorough assessment is of equal importance when planning resin bonded bridgework as with
conventional designs.
Specific problems of loss of space through drifting may pose problems with pontic construction. The occlusion
should allow sufficient space for the prosthesis after tooth preparation.
As in conventional bridgework, study casts are a useful tool in the assessment of occlusal factors, desired path of
insertion and possible need for orthodontic treatment.

Indications / contraindications

Replacement of a single missing tooth in an otherwise intact dentition.


Replacement of two teeth where the occlusion is favourable using two cantilevers.
Resin bonded bridges are contraindicated in situations where heavily restored abutments are present or
when the shape of the abutments requires considerable alteration to produce an aesthetic design.
Be aware of 'greying through' anteriorly.

Bridge design
As with conventional bridgework several designs of bridge are available. In recent years, the direct cantilever design
has gained favour. It is important that if this design is used the occlusion should be carefully managed. To prevent
rotation forces the pontic should contact the opposing teeth only in centric occlusion. All excursive contacts should
be eliminated.

Framework design
Non-perforated designs are preferred which have been sandblasted to allow retention.
Care should be taken to avoid producing aesthetically compromising grey areas where the metal may show through
translucent incisal edges.
Embrasure spaces should be created to allow adequate approximal and pontic surface cleansing.
For posterior frameworks, a greater thickness of casting is required to resist the forces of mastication. Occlusal rests
and varying degrees of occlusal coverage may be incorporated in these frameworks to produce positive seating and
resistance form.
L-3

Clinical stages
Preparation
Prior to preparation, the proposed extent and position of retainers should be identified on the study casts. Think
about the path of insertion, resistance and retention forms and space availability for metal. This should give you a
better idea if preparation of whole surface is required or if minor adjustments to remove undercuts are enough
(remember that not prepared areas will end up with positive margins once the RBB is cemented).
To ensure optimum bond strength, wherever possible, the preparation should be confined to enamel.
Supragingival chamfer finishing margins or removal of undercuts (enough for knife edge finishing margins) are then
created to provide sufficient wrap around (ideally 180 degrees) to provide resistance form. Cingulum and occlusal
rests are then added to aid in seating the framework.
Careful assessment of the occlusal clearance in both intercuspal and excursive movements should be carried out
prior to and during tooth modification to ensure sufficient space exists for the framework.

Principles of preparation
The following features should be incorporated in the design of the bridge:

A definite path of insertion.


Sufficient inter-occlusal clearance to provide a minimum thickness of 0.5mm metal.
Wrap around (180) to prevent displacement in other directions.
Positive seating form by allowing the
incorporation of rests.
Well-defined supragingival margins
(chamfer or knife edge), where
preparation is required (always drawn
on model the margin limits to aid the
technician).
For root filled teeth a shallow
preparation into the access cavity can
assist retention and resistance.
Avoid double abutments.

Figure L1 - RRB preparation if the tooth has had endodontic access.

Impressions
Where margins are unavoidably close to the gingival margins retraction procedures may be required. Impressions
should be recorded with a silicone impression material.
Temporary cover is rarely required. Composite resin may be bonded onto the teeth opposing the prepared
abutment teeth to prevent overeruption.

Try in
The retention and stability of the framework should be checked first followed by the marginal fit, occusal contacts,
embrasure space and thickness.
The fitting surface of the framework should then be sand blasted with 50-micron aluminium oxide, washed
ultrasonically and air-dried. If the bridge has been delivered from the laboratory having already been sandblasted,
following the try in, the fitting surface should be thoroughly cleaned to remove any contamination (you can
L-4

decontaminate it for 10 min in Perform ID then have it re-sandblasted by the lab or apply 35% phosphoric acid for at
least 30 sec and wash it thoroughly).

Bonding of RBB
Rubber dam is essential to avoid contamination with saliva, gingival fluid and blood during the bonding procedure.
The abutment teeth should be cleaned with pumice and water prior to acid etching with orthophosphoric acid.
Cellulose strips may be used to prevent inadvertent etching of the adjacent teeth.
The adhesive resin (Panavia 2.0, Rely-X Ultimate) is then placed on the sandblasted surface of the retainer wing and
the bridge inserted with firm pressure. Following removal of the excess cement, a coating agent (Oxy-guard) should
be placed over the exposed resin margins to ensure complete set of the cement.
The occlusion of the bridge should be rechecked at this stage. It is then advisable to arrange a review appointment
to ensure that no excess resin remains. At that visit, the importance of cleansing interdentally and beneath the
pontic should be stressed.

Conventional bridgework
Types of bridges
Fixed-fixed
Abutment teeth are rigidly splinted together; therefore, preparations must be parallel so that the bridge can be
cemented in one piece. As a design it is destructive and failures can go unnoticed if one retainer remains firmly
cemented it is therefore not the first choice of design in most cases.

Fixed-moveable
This design has a rigid connector at one end (major retainer) and has a moveable connector (minor retainer) at the
other. This allows some movement between abutment teeth. This is essentially a stress breaking design and may be
used to protect weaker abutments; e.g. those with reduced support or which have been root treated.
As the retainers in this design may be prepared with differing paths of insertion, it is often possible to be more
conservative with regard to tooth preparation. However, the preparation must include a slot for the fixed moveable
joint. This is usually positioned on the distal aspect of the mesial abutment tooth (except the upper centrals).

Cantilever
The direct cantilever bridge allows a pontic to be retained by an abutment at one end of the edentulous space. It is
possible to cantilever 1 unit in the anterior part of the mouth and 0.5 unit in the posterior. Care should be taken to
ensure the pontic is relieved from contact with the opposing teeth in excursive movements as this may result in
rotation forces on the abutment.

Spring cantilever
Of historical interest now, however there are still plenty in use and their recognition and evaluation is necessary.
Essentially this is a mucosal supported tooth retained restoration. The pontic is retained on a bar attached to a
distant retainer gaining support from the underlying mucosa. The design is of use when the abutment teeth either
side of the edentulous space are considered unsatisfactory as bridge retainers or are un-restored teeth. In the latter
situation the bridge has largely been superseded by resin bonded bridgework.

L-5

Luting agents for conventional bridgework


An increasing number of luting agents are available for use with crown and bridge restorations. For conventional
bridgework zinc phosphate is still regarded as the standard, it is also more retrievable than adhesive cements. In
situations where retention is at a premium, adhesive composite systems in combination with sandblasting or tinplating the fitting surface of the bridge retainer can be helpful. Rely-X Unicem, Rely-X Ultimate and Panavia 2.0 are
available for such situations.

L-6

Radiographic assessment
Radiographic assessment ......................................................................................................................................... M-1
Introduction ............................................................................................................................................................. M-1
Selection criteria for radiographs ........................................................................................................................... M-1
Diagnosis of dental caries ................................................................................................................................... M-1
Assessment of periodontal disease .................................................................................................................... M-1
Guidelines on writing a radiographic report .......................................................................................................... M-2
Example of radiographic report ............................................................................................................................... M-3

Introduction
Radiographs should be requested only after taking the patient's medical history and completing a full clinical
examination, in this way they are likely to contribute to a clinical diagnosis and management. When requesting a
radiograph the student should always ask the question 'will this radiograph affect the patient's management or
prognosis?'. If the answer to this is no, then a radiograph is not necessary.
Some guidelines are provided bellow to help students decide which and when these might be appropriate.

Selection criteria (FGDP 2004)


Diagnosis of dental caries
Caries Risk

Frequency of radiograph

High

Posterior BWs at 6 month intervals.

Moderate

Posterior BWs at 12 month intervals.

Low

Primary dentition: 12 - 18 month intervals.


Permanent dentition: 2 year intervals.

Assessment of periodontal disease


Lesion

Radiograph

Uniform pockets 5mm, little or no recession, (BPE 3)

Horizontal BWs.

Pocketing of > 5mm, (BPE 4)

Vertical BWs supplemented, if necessary, by PAs.

Irregular pocketing

Horizontal or vertical BWs depending on pocket depth


supplemented, if necessary, by PAs.

Concurrent problems (e.g. symptomatic 8s, multiple


crowns and/or heavily restored teeth and/or multiple
endo)

OPT supplemented, if necessary, by PAs.

Perio-endo lesion

PA.

M-1

Guidelines on writing a radiographic report

Check that radiographs are correctly marked with patient identifier and orientated correctly.
Include the date and type of radiograph on your report.
Comment on image quality (comment on any faults or artefacts that may affect the diagnosis or detract from
the image).
If there are several radiographs to examine, do them chronologically.
If previous films are present, they may be relevant if looking at the progression of lesions. Mention it on the
end of the report in a summary.
Have a method of going round the entire radiograph e.g. if a panoramic is being reported, start on the top
right, going left, lower left to lower right.

Periodontal:
Alveolar bone levels (if the apex can be seen then the bone loss should be measured as a percentage of root
length in 10% grades. If you cannot see the apices (e.g. bitewings), then bone loss should be measured in
mm).
Summarise the pattern of bone loss, i.e. is it generally horizontal or irregular with multiple vertical defects?
Is there variation in the horizontal loss i.e. a range 30-50%? Is the mandible different from the maxilla as
regards pattern or severity?
If calculus deposits are seen on a number of teeth, then simply say that, rather than laboriously listing every
piece seen. If there is a particularly large piece seen with an associated vertical defect then this may be
worth listing separately. plaque-retaining factors.
Furcation involvements.
Marginal widening.
Combined perio-endo lesions.
Caries:
Site.
Depth.
Restorations:
There is no need to mention every single restoration. But it is worth to mention heavily-restored teeth.
Must mention them if deficiencies, overhangs or leaking is observed.
Endodontic and periapical:
Periapical radiolucencies.
Also, the apical status of crowned teeth should be carefully examined.
Widening of periodontal membrane space.
Quality of root canal fillings (extruded / short from apex by how many mm? GP well or poorly condensed?
voids observed in coronal / middle / apical 1/3 of which root(s)?) or posts.
Other:

Presence of a retained root and, if relevant, their relationship with anatomical structures.
Radio-opacities.
Unerupted teeth if past their normal eruption date.
Third molars should normally be classified into their degree of eruption, any abnormal angulation and
particularly in the case of lowers, their root morphology and relation to the ID canal.
M-2

Finally, look at the areas of the radiograph out with the dentition in case there is further pathology.

Example - radiographic report


Upper and lower, right and left PAs of posterior teeth dated 20/11/13.
Image quality excellent.
No previous films for comparison.
Heavily restored dentition.
Periodontal
Generally, minimal 10-20% horizontal alveolar bone loss.
Probable perio-endo lesion UR6 and UL6, where there are retained roots.
UL7 has a short trunk and early furcation involvement.
Some calculus deposits evident distal UL7 LL7.
Caries
Grossly broken down retained roots at UR6, UL5 and UL6.
UR5 distal caries.
UL7 mesial recurrent caries.
Restorations
Extensive restorations on all remaining molar teeth.
Nayyar core type restorations on LR6, LR7.
Poorly contoured proximal contact LR6, LR7.
Negative margin distal LR6.
Endodontic and periapical
There are periapical inflammatory lesions associated with retained roots at UL5, UL6 and UR6.
Good, well-condensed root canal fillings LR6, LR7.
Minor extrusion of root canal filling distal root LR6, but no associated periapical pathology.
Loss of lamina dura and faint radiolucency mesial root LR6. It cannot be said without previous radiographs
whether this is increasing in size, or healing and decreasing in size.
Other
Retained roots at UR6 and UL6.
UR6 retained root is closely associated with the floor of the maxillary sinus.

M-3

Quick guide to restorative materials


Quick guide to restorative materials ....................................................................................................................... N-1
Introduction .............................................................................................................................................................. N-1
Permanent and temporary restorative materials ................................................................................................... N-1
Amalgam .............................................................................................................................................................. N-1
Chemfil Rock (GIC) ............................................................................................................................................... N-2
Fuji Triage (GIC).................................................................................................................................................... N-2
Fuji II LC (RMGIC) ................................................................................................................................................. N-2
Bases / liners ............................................................................................................................................................ N-2
Fuji Lining (RMGIC) .............................................................................................................................................. N-2
Dycal (setting calcium hydroxide)........................................................................................................................ N-3
Luting cements ......................................................................................................................................................... N-3
Fuji Plus (RMGIC) ................................................................................................................................................. N-3
Panavia 2.0 (resin composite).............................................................................................................................. N-3
Rely X Ultimate (resin composite) ....................................................................................................................... N-3
Rely X Unicem (resin composite) ......................................................................................................................... N-3
DeTrey Zinc (zinc phosphate) .............................................................................................................................. N-3
Others ....................................................................................................................................................................... N-4
Kalzinol (zinc-oxide eugenol) ............................................................................................................................... N-4

Introduction
This is not an exhaustive list of all restorative materials available in clinics, but certainly some of the most frequently
used. They are displayed here for quick consultation about mixing or working time along with some additional
information.
Material

Mixing
time

Indications

Working /
setting
time

Permanent and temporary restorative materials

Amalgam

Capsules with grey


plunger (20g alloy, 20g
mercury) for small
restorations.

Mixing
time:
5"

Condensing
time:

4'30''
Carving
time:
5'30''

Capsules with green


plunger (alloy 30g,
mercury 30g) for larger
N-1

Do / Do not

restorations.
Class III restorations.
ChemFil Rock
(GIC)
(A1, A2, A3)

Class V, root surface caries


/ cervical erosion.

Mixing
time:
15"

Class I/II semi-permanent


restorations.

Working
time:
1'30"

No conditioning.

Setting
time:
6'

Wait 6' after activation for finishing under


air water spray.

ChemFil Rock
(GIC)

No light-curing.

2 coats of varnish or unfilled composite


resin should be applied immediately
following restoration.

Intermediate endodontic
sealing.

(Contrast white)
Mixing
time:
10"
Fuji Triage
(GIC)

Intermediate endodontic
sealing.

Working
time:
1'40"

Conditioning is optional (for optimum


bond GC Cavity Conditioner for 10s, wash
20").

Setting
time:
2'30''

Light-curing is optional (for faster setting


light cure for 20 - 40'').

(Pink)

Wait 6' (chemically set) after activation for


finishing under air water spray or 4' if light
cured.
2 coats of varnish or unfilled composite
resin should be applied immediately
following restoration.

Class III restorations.


Class V, root surface caries
/ cervical erosion.
Fuji II LC
(RMGIC)
(A2 & A3)

Mixing
time:
10"

Working
time:
3'15"

Class I/II semi-permanent


restorations.

Restoration: Just prepare the cavity and


apply GC Cavity Conditioner for 10" to
remove the smear layer and seal the dentin
tubules. Place the mixed Fuji II LC into the
cavity. Light cure, trim and finish.
Liner/Base: Prepare cavity, apply GC Cavity
Conditioner for 10" and rinse for 20". Place
mixed Fuji II LC as a base or liner, then
light-cure for 20". Acid etch as needed,
apply enamel bonding agent and finish the
restoration with composite.

Liner under amalgam or


composite restorations.
Base under amalgam,
composite or porcelain
inlays and onlays.

Bases / liners
Fuji Lining
(RMGIC)

Base / liner in prepared


cavities.
Sealing pulpal floor and

Mixing
time:
10"

Working
time:
2'15"
N-2

Conditioning is optional (for optimum bond


GC Cavity Conditioner for 10s, wash 20").

gutta percha in endo.

Light cure for 20".

For bonding amalgam.


Mixing
time:
10"

Dycal
(setting calcium
hydroxide)

Vital pulpal exposure.

Working
time:
2'20"

No conditioning.

Setting
time:
2'30'' to
3'30''

Needs to be sealed in with another


material such as GIC / RMGIC.

No light-curing.

Luting cements
Mixing
time:
10"
Fuji Plus
(RMGIC)

Working
time:
2'30"

Ceramic, composite,
metal:

Setting
time:
4'30"

Inlay, onlay, crown or


bridges.

In combination with the GC Fuji PLUS


Conditioner for optimal marginal seal
Apply the mixed cement to both
restoration and prepared tooth.
Seat the restoration within 30 seconds of
completing mixing.
After finishing apply Fuji Coat LC or Fuji
Varnish to protect the GIC during the first
24 hours.

Panavia F 2.0
See step-by-step guide

(resin
composite)
Rely X Ultimate
(resin
composite)

Ceramic, composite,
metal:

See step-by-step guide

Inlay, onlay, crown,


bridge, veneer, posts.

Rely X Unicem
See step-by-step guide

(resin
composite)

DeTrey Zinc
(zinc phosphate)

Metal crowns.

Mixing
time:
1'30''

Working
time:
2'30''
Setting
time:
5' to 6'

Cast metal posts.

N-3

Mixing: Place an appropriate amount of


powder and liquid on a clean and dry glass
slab. Divide powder into small portions
using a stainless steel spatula. Add these
portions one by one to the liquid,
spatulating thoroughly after each addition.
A smooth and creamy mix should be

obtained.
Others

Kalzinol
(zinc-oxide
eugenol)

Soothing temporary filling.

Mixing
time:
1' to
1'30"

Working
time:
2'
Setting
time:
3'30'' to
4'30''

N-4

Mixing Ratio: Powder liquid ratio 5 : 1 (by


weight).

Prosthetics
Clinical Stages .................................................................................................................................................. O-3
History, Examination and Treatment Plan ................................................................................................. O-3
History ............................................................................................................................................................ O-3
Examination.................................................................................................................................................... O-3
Extra and intra oral ................................................................................................................................. O-4
Assessment of dentures ......................................................................................................................... O-6
Further investigations ............................................................................................................................. O-8
Diagnoses ....................................................................................................................................................... O-9
Treatment Plan............................................................................................................................................... O-9
Plaque control ......................................................................................................................................... O-9

The sequence of providing dentures ..................................................................................................... O-11


Preliminary impressions .............................................................................................................................. O-12
Tray modification ......................................................................................................................................... O-13
Laboratory prescription................................................................................................................................ O-14

A guide to the choice of special trays .................................................................................................... O-14


Disinfection and infection control ............................................................................................................. O-15
Partial Denture Design ................................................................................................................................. O-16
Problem Designs ........................................................................................................................................... O-17
Class IV upper dentures................................................................................................................................ O-18
Lower free end saddles ................................................................................................................................ O-19
Design of acrylic partial dentures................................................................................................................. O-19

Tooth Preparation for partial dentures .................................................................................................... O-20


Selection of abutment teeth ........................................................................................................................ O-20
Rest seat preparation ................................................................................................................................... O-20
Creation of guide surfaces............................................................................................................................ O-21
Modifying the survey line............................................................................................................................. O-22
Modifying tooth shape for minor connectors .............................................................................................. O-23

Working impressions .................................................................................................................................... O-24


Modification of the special trays.................................................................................................................. O-24
Application of Adhesive................................................................................................................................ O-26
Taking the impression .................................................................................................................................. O-26
Lower free-end saddle impressions ............................................................................................................. O-26
O-1

Laboratory prescription................................................................................................................................ O-27

Trying in the framework .............................................................................................................................. O-28


Recording the occlusion ............................................................................................................................... O-29
Wax Try in ...................................................................................................................................................... O-32
Fitting the dentures ...................................................................................................................................... O-34
Prosthetic burs ............................................................................................................................................. O-35

Advice to the patients .................................................................................................................................. O-36


Review............................................................................................................................................................. O-37
Immediate Dentures .................................................................................................................................... O-38
Copy dentures................................................................................................................................................ O-39
Introduction ................................................................................................................................................. O-39
Indications .................................................................................................................................................... O-39
Procedure ..................................................................................................................................................... O-39

Reline / Rebase.............................................................................................................................................. O-45


Laboratory reline / rebase............................................................................................................................ O-45
Chairside reline............................................................................................................................................. O-47
Soft lining materials...................................................................................................................................... O-48

Aide Memoirs .................................................................................................................................................... O-51


Evaluation of the patient and dentures ....................................................................................................... O-51
Primary Impressions ..................................................................................................................................... O-52
Secondary impressions................................................................................................................................. O-53
Recording the occlusion ............................................................................................................................... O-54
Wax try in ..................................................................................................................................................... O-56
Fitting the dentures ...................................................................................................................................... O-57
Partial denture design .................................................................................................................................. O-60
Essential reading .................................................................................................................................................. O-61

Paul Franklin
Senior Clinical Teaching Fellow

O-2

Prosthetics
History, Examination and Treatment Plan ................................................................................................. O-3
History ............................................................................................................................................................ O-3
Examination.................................................................................................................................................... O-3
Extra and intra oral ................................................................................................................................. O-4
Assessment of dentures ......................................................................................................................... O-6
Further investigations ............................................................................................................................. O-8
Diagnoses ....................................................................................................................................................... O-9
Treatment Plan............................................................................................................................................... O-9
Plaque control ......................................................................................................................................... O-9

The sequence of providing dentures ..................................................................................................... O-11

History, Examination and Treatment Plan


History
During the history taking it is important to try to get know the patient, find out what their complaints and
expectations are and try to find out how successful a denture wearer they have been in the past. The social and
medical history may give some clues as to the potential success of future dentures and the availability of the patients
for appointments.
Try to establish a rapport with the patient and find out what is important to them.
In addition to taking a standard history, the following additional factors need to be considered for denture patients;

C/O
Complaint, concern or reason for attendance, using patients own words where appropriate. Find out
the impact of missing teeth and the problems they are having, if any, with current dentures. If problems are
aesthetic then detail exactly what they mean.

HPC
History of present complaint (including duration, location, nature, modifying factors, relationship to
the provision of the existing dentures). For example if the dentures are loose then ask when are they loose
and for how long have they been a problem.

PDH If they are wearing dentures ask about previous sets and how successful they have been, if possible
ask patients to bring previous sets with them so that design features can be examined to see what has or has
not been successful for that patient. If the patient is edentulous find out for how long they have been
edentulous.

SH

Including smoking, alcohol, availability for appointments.

MH

Being particularly aware of drugs that can cause dry mouth.

O-3

Examination
The examination should consist of a full charting and periodontal screening if the patient is dentate. Edentulous
areas should be examined for suitability as a denture support area and for any pathology that may or may not be
related to the patients dentures.

Extra Oral
Includes assessment of skeletal classification, biological age, facial habits, appearance, occlusal vertical dimension.
Look for evidence of over closure which occurs with inadequate OVD and watch the patient as they are speaking to
gauge some insight into the sufficiency of the freeway space.
Assess appearance as affected by the dentures, e.g. facial and lip support, naso-labial angle, creasing and folds at the
corners of the mouth, and midlines.

Patient with teeth in occlusion showing marked


overclosure

Patient at rest

Intra oral
The broad objective is to check on the health of the oral tissues and to make a note of any condition which adversely
affects the prognosis of dentures. This is achieved by examination and by palpation. You should aim to describe in
some detail the morphology of the mouth, including size and shape of the upper and lower ridges, shape and depth
of sulci, the presence of high muscle attachments, the condition of the oral mucosa, particularly that covering the
denture bearing area, quantity and quality of saliva. The size and shape of the tongue and mobility of the floor of
mouth.
Chart any teeth present and carry out a BPE if appropriate.
Look for any adverse effects caused by the existing dentures;

O-4

Figure 1 - Lower denture that is not adequately supported and covering gingival margins can cause build up of plaque and interfere with
plaque control unless patient is adequately educated. This can lead to periodontal disease. It can also lead to direct gingival trauma.

Occlusion
For edentulous patients note;

Skeletal classification
Overclosure
Slide from centric relation to centric occlusion
Freedom to slide laterally without interference or locking

For partially dentate patients note;

Angles incisor classification


Canine guidance or group function
Presence of wear facets that may indicate attrition
Over eruption or overclosure making insufficient room for dentures
Presence or absence of a stable occlusion or occlusal stop to assist in OVD determination
Presence of retained roots and potential for overdenture abutments

Some examples;

Traumatic complete
overbite

Traumatic occlusion 22

O-5

Unstable occlusion with no


reproducible occlusal stop

Unstable occlusion but


with reproducible occlusal
stop

Assessment of dentures
Upper denture alone (remove lower)
Retention and stability

Ask the patient to half open the mouth and observe if


the upper denture falls spontaneously
For complete dentures hold firmly the premolar teeth
on either side and pull vertically downwards, a
denture with good border seal should be difficult to
displace
Using thumbs on occlusal surface see if the denture
can be rocked antero-posteriorly or side-to-side
Try to rotate the denture it should have less than
5mm lateral displacement
Look at tooth position of the posterior teeth, the upper palatal cusps should lie over the ridge. The incisor
teeth should be positioned 10-12 mm in front of the incisive papilla this can be determined with an Alma
Gauge
Examine borders of the denture for over or under extension. Paying particular attention to the tuberosity
regions and also the post-dam

Lower denture alone

The mouth is opened 20mm with tongue in relaxed position. Seating of denture checked with fingers placed
on the occlusal surface
The patient is instructed to move the tongue so the tip gently rests at the angles of the mouth with mouth
opened 20mm. Check seating of denture with fingers placed on the occlusal surface (Repeat three times.
Make judgement at third attempt)
The lower denture is held against the ridge by a finger and thumb in the incisor region and attempt is made
to move it in an antero-posterior direction with tongue in relaxed position
O-6

Tooth position the central fossae of posterior teeth should be directly above the ridge, lower incisor teeth
should have the necks of the teeth over the ridge but the incisal edges may be proclined or retroclined
Examine borders of the denture for over or under extension
Measure RVD with lower denture in place and upper removed

Figure 2 - Consider all of the factors that may be having a positive or negative influence on retention and stability

Both dentures together


Holding the lower denture firmly in place using the borders of the denture bring the patient into occlusion in the
most retruded position, feeling for initial contacts or any deviation as they close.
Look out for;

Balanced, even meeting of teeth


Consistent return to centric or habitual
Slide > 2mm. No consistent return
Uneven contact (one or all of these)

Articulation
Lower jaw moved side to side with teeth lightly
together. Observe relationship of denture bases to
underlying tissues. Watch for;

Minimal displacement or patient unable to


make the movement
Excessive displacement
Occlusion locked

O-7

Incision Test:
Cotton wool roll is inserted between the front teeth
and the patient is instructed to close gently onto the
roll and then bite as if into a piece of food. The
position of the tongue is noted. (Make judgement on
third attempt)

The upper denture is stabilised by the


patient's tongue
The upper denture is not re-seated, and the
tongue remains in the floor of the mouth

The patient should be able


to stabilise the upper
denture with their tongue
during incision

Other items you may wish to include in your examination:denture material, presence of denture plaque,
occlusal wear, shiny wear facets, shape of polished surface, post dam, a comparison of shapes of current and
previous dentures. Presence or absence of anterior flanges.

Further investigations
Radiographs, microscopical smears from denture or mucosa, blood tests etc, should be carried out where
appropriate.

Figure 3 - Good quality Panoramic radiograph to assess abutment teeth and general bone levels

O-8

Figure 4 - Periapical radiographs of abutment teeth

Diagnoses
Using the information acquired so far, the diagnosis should be identified and recorded. Unless this can be achieved
and there is a prospect of improvement, treatment involving the provision of new dentures should not normally be
undertaken.
The diagnosis should be specific. For instance, an inadequate diagnosis would be unretentive upper complete
denture the more specific diagnosis might be unretentive upper complete denture due to alveolar bone
resorption. Remember, a good rule of thumb for all clinicians is not to initiate a treatment plan without a diagnosis
firmly established No Diagnosis No Treatment.

Treatment Plan
It is essential to assess the advantages and disadvantages of a denture for each patient and to decide on the
provision of a denture only if the advantages clearly outweigh the disadvantages and if the evidence indicates that it
is in the best interests of the patient. Missing teeth do not invariably require prosthetic replacement. As a general
rule you should provide a replacement denture only if you can see clearly how to improve on the existing one.
Any surgical, conservative or periodontal treatment must be completed before taking working impressions for the
new denture. The exception to this is in an emergency situation (eg following the traumatic loss of anterior teeth).

Plaque control
The patient's level of plaque control is the single most important factor determining the prognosis of partial
dentures. It is essential for the patient to maintain a high level of plaque control if damage to the teeth and gums by
the denture is to be avoided. You must always seek to maintain or improve the patient's motivation and technique.
The state of the mouth, when the patient is first seen, and the likely response of the patient to advice and
encouragement will significantly influence the decision on whether or not to fit partial dentures, and if so, what type
to supply.

Figure 5 - Treatment is required before providing new denture

Figure 6 - Healthy mouth suitable for denture construction

Thus, during the preliminary stages of treatment you must produce documentation on plaque scores. Unless there is
evidence of either a high level of plaque control or of gradual improvement, you should give serious consideration as

O-9

whether an RPD should be provided. Should a patient fail to demonstrate a good standard of oral hygiene, it may be
acceptable to provide a well-fitting acrylic transitional denture.
When replacement dentures are to be provided draw up a 'shopping list' of aspects of the old dentures which are to
be altered and aspects which are to be retained. This information is to be included in the Restorative Dentistry
diagnostic sheet.
An example would be :Retained features

Upper complete denture appropriate extensions


Appropriate shade and mould of teeth

Features to alter

Correct tongue crowding of the lower complete denture


Address lower posterior teeth neutral zone
Correct under-extensions posterior-lingually on right and left of lower complete denture
Reduce overextension posterior-buccally on right and left of lower complete denture

Normally, a design must be produced before other dental


treatment is carried out because the type of denture is likely to
influence the overall treatment plan, e.g. a rest seat may be
incorporated into a Class II restoration: a full veneer crown
may be contoured to provide an ideal shape for retention and
support: a tooth may be extracted instead of restored because
it has overerupted and would interfere with the fitting of a
partial denture.
Discuss with the patient any limitations of dentures which may
have become apparent during the assessment stage.

O-10

Figure 7 - Mounted study models

The sequence of providing dentures


All dentures and patients are different, and the sequence of the denture stages. The following table shows some of
the more likely treatment sequences, you should discuss with your tutor which one is most suitable for your patient

Stage

Conventional complete
dentures and simple
acrylic partial dentures

Copy / replica
complete dentures

Simple cobalt chrome


partial dentures

Complex partial
denture cases including
provision of multiple
crowns or changes to
OVD

Primary impressions

Moulds of existing
dentures

Primary impressions

Secondary impressions

Record occlusion using


replicas

Primary jaw registration


Primary jaw registration
Design

Record occlusion

Wax try in
Wash impression

Tooth modification /
Secondary impressions

Wax try in to establish


desired OVD / Aesthetic
changes

Primary impressions

Wax try in

Fit

Try in metal framework


Add wax and record
occlusion*

Carry out tooth


modifications / Crowns
using wax try in for
clinician and technician
as a guide to work to

Fit

Review

Wax try in

Secondary impression

Fit

Try in metal framework


incorporating previous
wax try in

Review

7
8

Review

Fit
Review

* The metal try in should be carried out without any wax record rims on the framework. If time allows and you feel
you have sufficient technical ability wax rims may be created at chair side and the occlusion recorded, otherwise the
metal framework should be returned to the lab for the rims to be added.

O-11

Prosthetics
Preliminary impressions .............................................................................................................................. O-12
Tray modification ......................................................................................................................................... O-13
Laboratory prescription................................................................................................................................ O-14

A guide to the choice of special trays .................................................................................................... O-14


Disinfection and infection control ............................................................................................................. O-15

Preliminary impressions
Primary impressions are usually taken in alginate
Choose an appropriate stock tray

Upper edentulous tray


Upper dentate tray

lower edentulous tray

lower dentate tray

Figure 1 - "Solo impression trays for primary impressions"

O-12

Tray modification
Alginate needs to be supported as it cannot support itself beyond an extension of 3mm from the tray borders. This
means that edentulous areas and borders generally need modification with a self-supporting material prior to taking
the alginate impression.
The materials we use for the tray modification are impression compound or silicone putty.

Tray modified for lower free-end saddles using


impression compound prior to taking an
alginate impression

Impression compound primary impressions for


complete dentures

Silicone putty primary impression for complete


lower denture

Impression compound impression with alginate


wash, this is not always necessary if the
compound or silicone has been adequately
extended.

O-13

Final stage of the primary impression is to mark


on the extent of the desired special tray using
an indelible pencil. This is usually marked on
the inside of the impression 2mm short of the
full depth of the recorded sulcus

Impression compound is a thermoplastic material. You will need a flask of boiling water and a plastic bowl. To get
water of the correct temperature for compound (60-70C) part fill the bowl with boiling water then add some cold
until the temperature feels about the same as a hot drink. The compound is placed into the bowl to soften. Kneed
the material a little until it is soft throughout then load the tray, arranging the material to an approximation of the
final impression. Place the impression tray and compound back into the water bath to re heat then quite quickly
remove and carry out the impression. Be very careful that the water is not scalding. If defects are found with the
resultant impression it can usually be easily modified by warming and adding more impression material if required.
Where impression compound or silicone have been used to record and fill in an edentulous area it is important to cut
away any material that has gone onto the teeth leaving a 3mm margin between material and teeth.
Following tray modification the tray and supporting material should be sprayed with adhesive and an alginate
impression taken.
After the impression has been taken it should be marked with a line of indelible pencil showing the desired extension
of special tray (this is generally 2mm short of the recorded sulcus).
Also mark on the position of any required stops. These must form a tripod and for patients for whom a cobalt
chrome denture is being constructed should not be placed on abutment teeth.
For upper complete dentures the preferred pattern of stops is a wide stop extending across the post dam and a
smaller triangular stop in the incisive papilla region.

Laboratory prescription
Prescribe spaced or close fitting tray and indicate position of stops, types of handles and if finger rests are required.

A guide to the choice of special trays


Maxillary Arch
Condition

Tray Type
Impression
material

Edentulous
Minimal/No undercut

Edentulous
Flabby ridge or marked
bony undercut

Partially dentate

Close fitting
No perforations

Spaced
Lots of perforations

Spaced
Perforated

Light bodied silicone

Medium bodied silicone or


alginate

Alginate if few standing teeth or teeth


with recession present
Medium bodied silicone otherwise

Mandibular Arch
O-14

Condition

Minimal/No undercut

Tray Type

Close fitting
No perforations

Impression
material

Light/medium bodied
silicone

Marked bony undercut

Spaced
Perforated
Alginate or medium bodied
silicone

Partially dentate
Spaced over teeth, close fitting over free
end saddle regions
Perforated where teeth are only, no
perforations over saddles
Alginate if few standing teeth or teeth
with recession present
Medium bodied silicone otherwise

Disinfection and Infection control


Before sending any work to the laboratory it should be disinfected in the Perform bath in the unit for 10 minutes
prior to rinsing and appropriate storage for transit to the lab. If there has been any blood contamination of any
objects they should be thoroughly rinsed prior to immersion in the perform bath.

O-15

Prosthetics
Partial Denture Design ................................................................................................................................. O-16
Problem Designs ........................................................................................................................................... O-17
Class IV upper dentures................................................................................................................................ O-18
Lower free end saddles ................................................................................................................................ O-19
Design of acrylic partial dentures................................................................................................................. O-19

Tooth Preparation for partial dentures .................................................................................................... O-20


Selection of abutment teeth ........................................................................................................................ O-20
Rest seat preparation ................................................................................................................................... O-20
Creation of guide surfaces............................................................................................................................ O-21
Modifying the survey line............................................................................................................................. O-22
Modifying tooth shape for minor connectors .............................................................................................. O-23

Partial Denture Design


The students are expected to have surveyed the model and come up with a preliminary denture design prior to the
patients next appointment. This can be carried out on level 6 with the help of the technical demonstrators.
As a simple guideline to denture design the following rules are advocated;
Saddles

Identify which teeth need to be replaced and those that do not


Extend fully where support is needed
Draw to indicate flanges

Support

Tooth support where possible for all acrylic dentures any colleting should be positioned above the survey
line. For cobalt chrome dentures rests of at least 1mm thick should be used
Rests are most effective when closest to the saddle
For lower free end saddles use the side of the abutment tooth away from the saddle

Retention

Survey to identify path of insertion usually perpendicular to occlusal plane unless model needs to be tilted
Prepare guide planes to optimise retention wrap around design, stay within enamel, optimally at least
3mm in the vertical dimension
Identify usable undercuts and modify teeth if there are not suitable undercuts where needed
Clasps are most effective if positioned at either end of a saddle
For molars usually occlusally approaching ring clasps and 3-arm clasps
For premolars usually gingivally approaching e.g. I-bars
Draw retentive clasp arms on tooth surface identified by an arrow head
O-16

Employ cross arch reciprocation e.g. if using buccal undercuts on one side of the mouth try to use buccal
undercuts on the opposite side

Reciprocation

Try to avoid simple reciprocal arms unless they are on a guide surface
Either major connector or minor connector staying in contact with opposite side of tooth from retentive
clasp arm

Connectors

Simpler the better


Rigid
Gingival clearance where possible

Then
Consider the need for indirect retention

Only required if direct retention is not possible or optimal


Identify clasp axis
Positioned as far the other side of clasp axis from saddle that requires retention

Bracing

Identify which components of the denture will resist lateral movement including posterior and side to side
displacement

Finally

Check to see that all components are connected together


Design is legible and annotated for the technician
Check design is suitable and not overcomplicated by too many clasps (usually no more than 3 necessary)

A good design should encompass the following features;


Adequate gingival clearance wherever possible without weakening the base or creating small difficult to
clean areas
Adequate support ideally each design should have 4 corners identified where the denture is adequately
supported by tooth supports or firm ridges
Rigidity it is favourable for all of the components of the denture to function as one unit and for no areas
beneath the denture to receive excessive load therefore a rigid design will help spread the load
Simplicity the simpler the design to achieve the above principals, the easier will be the casting process for
the technician and easier for the patient to keep clean. To simplify designs think about whether all teeth
really need replacing and whether clasps can be reduced in number by using guide planes or indirect
retention wherever a clasp axis exists

Problem Designs
Occasionally patients present with very limited interocclusal space. Metal backings will need to be considered to
reduce the incidence of fracture of acrylic teeth.

O-17

Figure 1 - Lack of interocclusal space and potential for fracture of anterior teeth from denture

The position and appearance of the artificial teeth must be confirmed with the patient prior to the construction of
the metal work denture as adjustment afterwards is very limited, therefore the denture should be taken to the wax
try-in stage prior to production of the metal framework. The framework should later be tried in alone and the wax
try in incorporated into the framework for final try-in by the technician.

Figure 2 - Metal backings on palatal surface of incisors

Figure 3 - Thin coverage of metal work over palate reduces the


incidence of fractures

Class IV upper dentures


Gingival clearance
Forward pointing clasp arm

Indirect retention

Figure 4 - Features to include when providing an upper denture to replace anterior teeth

Problems

Aesthetics flange shade / shape. Creation of black triangles between denture and abutment teeth
Anterior bony undercuts
Direct retention from anterior teeth not generally advisable

Factors to consider in the design;


O-18

Heels down tilt to allow use of anterior bony undercut and reduce black triangles
Forward facing occlusally approaching clasps on molars more effective and attempt to shift the claps axis
forwards to allow opportunity for indirect retention
Indirect retention via posterior palatal bar if patient can tolerate or rest seats on teeth posterior to the
clasped teeth

Lower free end saddles


Problems;

Differential support
Lack of support posteriorly
Lack of bracing posteriorly
Lack of retention posteriorly
Torquing forces on abutment teeth
Major connector interfering with tongue

Design principals to apply;

Coverage of maximal denture bearing area on free end saddles onto retromolar pad and
Reduce occlusal table fewer, narrower teeth
Indirect retention
RPI system on premolar abutments

Mesial rest
Maximal tissue
support

Indirect retention
I-Bar

Figure 5 - Features to consider when providing lower free end saddle dentures

Design of acrylic partial dentures


The design of acrylic partial dentures should follow the same basic principles as for cobalt chrome dentures.
Generally a plate design will be required to give adequate strength and support.
Tooth support is more difficult so spreading the support over as wide an area as possible will help.
Colleting teeth is often necessary, it is ideal to position the collets above the survey line to offer some tooth support
and prevent gingival trauma. The lab should be instructed to block out any unwanted undercuts below the survey
line.
Wrought clasps can be used for undercuts of 0.5 mm, reciprocation via the denture base is still required.
Gingival clearance should be sought where possible, unless this would lead to weakening of the denture base.

O-19

Tooth Preparation for partial dentures


The clinical supervisor should check the design and in conjunction with a clinical inspection and review of recent
radiographs of abutment teeth. If all OK then they may approve the student to carry out the necessary tooth
preparation to allow the design to be constructed.

Selection of abutment teeth


Recent radiographs and clinical investigation should be reviewed to assess the teeth for;

Quality of coronal tissue


Absence of active disease
Quality of restorations present
Tooth vitality
Quality of any root fillings
Absence of periapical pathology
Periodontal support
Gingival health
Root length and angulation

Consider the risks / benefits of providing or replacing crowns for heavily restored teeth. This should obviously be
carried out prior to recording secondary impressions.

Rest seat preparation


Floor is at right angles to the long axis of the tooth
Slopes towards the cervical margin to be avoided (wedging
action)
Vertical loading achieved

Rounded proximal margins


(avoid sharp angles, this results in increased stresses of metal
hence failure)
Heavier and stronger in grinders and clenchers.
Ideally at least 1mm thickness of metal is required for durability

O-20

Broadest at point of attachment of rest to the saddle


Extend over the central axis of the tooth
Saucer shape keep within enamel

For anterior teeth it is best to either accentuate the natural


cungulum of the tooth or if the mesial or distal surface is
prepared it must not create an area of undercut relative to the
path of insertion

It is more conservative to create anterior rest seats using


composite materials, these should be bonded well and nonintrusive for the patient whilst the denture is out of the mouth

Creation of guide surfaces


Guide surfaces can dramatically increase the retention and stability of a partial denture. Ideally they should be
parallel to the path of insertion, but not necessarily parallel to the path of natural displacement.
Guide surface are best if they have greater than 3mm height, should wrap around the proximal surface of the tooth
and be kept wholly within enamel

O-21

Modifying the survey line


Often the survey line is not totally ideal for the design of the denture. The correct position of an occlusally
approaching clasp is for the proximal 2/3 of the clasp arm to run above the survey line and the distal 1/3 to be below,
with the clasp tip in an area of undercut appropriate to the material of the clasp.

0.25 mm
0.5 mm
0.75 mm

Cobalt Chrome
Wrought stainless steel
Wrought or cast gold

When assessing an area of undercut as suitable for a clasping arm, the depth should be measured using an undercut
depth gauge and the desired position for the tip of the clasp should be marked on the model to guide the technician.

Raising with composite


Composite can be used to create undercut where insufficient exists.
The composite should be well bonded and cover a largish surface area. The restoration should be raised but blend in
at the margins so that it is undetectable with a probe

Survey line too low

The composite should be smooth to allow easy transition


of the clasp into the undercut

Lowering by tooth preparation


O-22

If the survey line is high then it is possible


that the first 2/3 of the clasp arm might
interfere with the occlusion. This should
be corrected by careful tooth
preparation. A further impression and
survey may be required to assess
whether sufficient modification has been
carried out

Modifying tooth shape for minor connectors


Close inspection of the occlusion is required to see that all components can be connected to the major connector
without interfering with the occlusion

Small amount of tooth


preparation has been carried out
to prevent interference with the
occlusion. This must always
remain within enamel.

O-23

Prosthetics
Working impressions .................................................................................................................................... O-24
Modification of the special trays.................................................................................................................. O-24
Application of Adhesive................................................................................................................................ O-26
Taking the impression .................................................................................................................................. O-26
Lower free-end saddle impressions ............................................................................................................. O-26
Laboratory prescription................................................................................................................................ O-27

Working impressions
Modification of the special trays
Spaced trays should have had 'stops' added in the laboratory if they were asked for on the prescription, if not they
will be required to be added at chairside using greenstick prior to carrying out border moulding. Close fitting trays
obviously do not require 'stops' but any undercuts must be removed from the impression surface. Adjust the
borders to correct any under or over extension that is present. It will usually be necessary to seek additional
extension around the tuberosities and in the lingual pouches.
To identify over extension hold the tray firmly in position with one hand while manipulating the lips and cheeks /
tongue to simulate normal function and feel if the tray is being displaced by this action.
Over-extension:-

by using an acrylic trimmer

Under-extension:-

Apply greenstick tracing compound and muscle trim

NB
When using greenstick tracing compound, have available a bowl of hot water (60C) and a bunsen. Take
special care when wearing rubber gloves near naked flames.
For partial denture cases it is only important to record the function depth and width of the sulcus in edentulous area
and adjacent to teeth that are going to receive a gingivally approaching clasp.
It should be emphasised that the ultimate criterion for a close-fitting tray is that it is stable and retentive in the
mouth before the impression is taken. The borders of a close fitting tray should be 1-2mm short of the sulcus depth.
It should be remembered that this can be achieved in some instances by correcting over-extension only, in some
circumstances by selective additions of greenstick tracing compound and on some occasions by complete border
moulding.
When undertaking complete border moulding, greenstick tracing compound is applied incrementally where needed
having first dried the tray. A bunsen is used to heat and modify the greenstick tracing compound. The tray with
greenstick is then placed into the bowl containing warm water to temper the impression material prior to placing it
in the patient's mouth for border trimming. Any undercuts created on the inside of the tray by the greenstick should
be removed with a wax knife prior to recording the working impression (Please do not use a scalpel for this
purpose!)

O-24

Trays may be cut away from those parts of the mouth


which will not be covered by the denture. This will ease
removal of set impression and reduce distortion.
Check with a member of staff before embarking on
major tray reduction.

Selective areas have been modified with greenstick

Getting the correct width of sulcus is essential to


creating an appropriate border seal

Final light bodied silicone impression for lower


complete denture

O-25

Application of Adhesive
If an elastic material is used, an appropriate adhesive should be applied in a thin uniform layer over the whole of the
fitting surface and carried over the borders to include 2-3 mm of the outer surface of the tray.

Interdental spaces below contact points may need to be


blocked out with carding wax. Take care that the wax does
not encroach onto any surface which will be covered by any
part of the subsequent denture.

Taking the impression


Ensure that adequate impression material is conveyed to all the critical areas - if necessary, alginate may be smeared
onto prepared tooth surfaces, around tuberosities etc.
Once an impression has been removed from the mouth, ensure that any of the material which extends beyond the
tray is not allowed to rest on a rigid surface.

Lower free-end saddle impressions


When dealing with lower free-end saddles, it is possible to obtain a relatively muco-compressive impression of these
saddles at the time of recording the working impression by using greenstick tracing compound. The extension of the
tray is checked for overextension and trimmed as required.
The whole of the free-end saddle is coated with greenstick, which is then placed in a warm water bath (60C) to
temper. The tray is then placed in the mouth and seated until the 'stops' contact the teeth and prevent further
movement. Muscle trimming is completed and the tray removed. The greenstick impression is checked for voids,
undercuts are removed and then a low viscosity alginate is used to record the final working impression. If this
technique is carefully used it may not be necessary to complete an 'altered cast impression' at the metal try-in stage.

O-26

Borders of the Completed Impression


The impression should record both the functional depth and width of the sulcus so that the finished denture
maintains an effective facial seal. Indicate to the technician the width of border required by marking clearly on the
outer aspects (2mm beyond sulcus reflection) of the alginate impression in indelible pencil.
Note that the lines scribed on the preliminary impressions and the working impressions are drawn at a different site
and are scribed for a different reason, for each impression. The line drawn on the preliminary impression is
approximately 2mm before (or inside) the sulcus reflection and marks the extent of the required special tray. The
line drawn on the working impression is approximately 2mm beyond the sulcus impression and shows the technician
the full sulcus width (so the master cast is not over-trimmed so that the potential border seal is not lost when the
baseplate is fabricated).

Figure 1 - Impression has been disinfected and the border area protected by indicating to the lab the extent to be retained

Laboratory prescription
Delineate the borders of the impression.
Specify the material to be used for the record block bases.
a)
b)

Light-cured acrylic resin: For rigidity.


Shellac: Specifically indicated where the inter-ridge distance is small and where the position of the
post dam on the upper working impression is uncertain. Outline on the cast the extent of the shellac
especially where inter-ridge height is limited.
Heat-cured clear acrylic resin: In exceptional cases where you require optimum retention and stability. This base is
valuable when the prognosis for retention and stability is poor.

O-27

Trying in the framework


1) The following procedure should be followed:a) Examination of framework on the cast.
b) Check that the framework is the same as the original design
and drawing on the study cast.
c) Check the accuracy of fit of the components.
d) Check the position of the retentive and bracing arms relative
to the survey lines.
e) Inspect all components which are designed to be clear of the
gingival margin area, and check that the clearance is adequate.
Check design has been followed
f) Inspect the impression surface of connectors which are designed
to cover the gingival margin area. Remove only the sharp area of connector which fits into the gingival
crevice.
g) Check the stability of the framework.
h) Finally check the occlusion for clearance of all components.

Check components are seated

Check gingival clearance

2) Examination of the framework in the mouth.


a) Check those aspects mentioned above. Bear in mind the likelihood of some instability in free-end saddle
cases.
b) If upper and lower frameworks are to be tried in, try each independently. Check the occlusion of each
separately and then together, to ensure that there are no premature contacts. This should be done by visual
examination, comments from the patient and the use of articulating paper or occlusal indicator wax. Any
premature contact must be removed at this stage. Unless there is a planned increase to the OVD, the
patients occlusion and natural occlusal contacts should be the same with and without the framework in situ.
c) If major adjustments or a remake are required please liaise with the technician who constructed the metal
work. Good communication with your technician will help to prevent further problems.

Fully seated try-in.

Disclosing paste used to determine areas of the metal


work that need adjustment to aid seating.
O-28

Recording the occlusion


The purpose of this visit is to allow the technician to mount the patients models on an articulator, such that the
artificial teeth can be set up with the correct vertical and horizontal relationship, and with the correct occlusal plane.
We should also be guiding the position and arrangement of anterior teeth and indicating the shade and mould of any
denture teeth we would like them to use.

An obvious occlusion. No
need to register unless
premature contact
present.

An occlusal stop present


but casts are not stable
enough without the use of
an upper wax occlusal rim.

No occlusal stops. Requires


upper and lower wax
occlusal record rims.
Clinician will need to assess
appropriate OVD.

Where there is an obvious stable ICP that is not planned to be altered then the rims should be adjusted such that the
patient maintains the same tooth to tooth occlusal contacts whether the rims are in the mouth or out, and the rims
are adjusted to give the technician the required information for placement of anterior teeth including lip support,
incisal length and midline placement. To assist the lab further in tooth selection the position of the canines and
marking of the high smile line can be useful.
For patients with an occlusal stop but unstable models due to lack of numbers of teeth then the following technique
for complete denture recording should be adopted, but the desired OVD should be determined by tooth contacts
rather than calculating from the RVD.
For all cases where there are no occlusal contacts including complete dentures the following systematic approach
should be followed.
Upper record rim
Tried in and adjusted until comfortable

1) Correct lip support looking at the naso-labial angle of the patient


from the side and feeling the tension in the upper lip should give an
idea of whether there is sufficient lip support. Trim or add wax to
the labial surface to adjust.

O-29

2) Incisal level trim or add wax from the incisal area of the
record rim until the desired amount of tooth is showing with
the upper lip at rest. Patients frequently tense the upper lip
when a flange is present, so it is important to try to get them
to relax this. If the patient has no strong feelings about this or
there are no previous dentures to mimic, then about 1mm
showing at rest is generally about right, with maybe less for
very old patients.

3) Remember that the previous dentures provide


information on the appropriate horizontal and vertical
jaw relationship, height of the occlusal plane, incisal
level, relationship of teeth to the oral musculature etc.
The use of an Alma gauge can be helpful to compare
incisal positions in old and new dentures.

4) Using a Foxs plane guide and tongue spatula or


ruler assess the degree of parallelism to the Alartragal plane. Use the hotplate to adjust or add wax as
necessary. Try not to change the incisal level already
determined.

5) Still with the Foxs plane guide to help compare the horizontal plane with the interpupillary plane when
looking at the patient from the front.
6) Buccal corridors - The maxillary rim should touch the cheek mucosa in the buccal regions.
Lower record rim
Try in and adjust until comfortable. If the wax rim keeps popping up when not held down it may be over extended or
not in the neutral zone
1. Adjust for neutral zone by ensuring the rim is centralised over the ridge in all areas, then adjust and reduce width
if still interfering with normal tongue and cheek movements
O-30

2. Measure RVD and calculate desired OVD (creating a FWS of 2-4 mm). The presence of dentures in the mouth
modifies the rest position of the mandible and a more accurate measurement of the rest vertical dimension will
be achieved with the lower denture in place
Both record rims
1. Adjust the height of the lower rim until the correct OVD is reached. Do not adjust the upper rim any further.
2. Holding the lower rim firmly against the ridge, guide the patient into their retruded contact position. Do this a few
times until a repeatable position is reached. Score a line with the wax knife from upper to lower rim in the
premolar region. You should check that this line lines up again
later once the Blu mousse is in place.
3. Mark on the centre line by looking at the patient directly from in
front of them and judging the centre line as it passes down the
face.
4. Cut V notches in upper and lower rims posteriorly to allow
repositioning if they should come apart after the occlusion has
been recorded.
5. Apply silicone adhesive to the upper rim and return them to the
mouth.
6. Syringe Blu-mousse around the lower rim and holding the rims firmly
seated on the ridges guide the patient into their RCP. Look at the check
lines and centre lines you scored earlier to see that they have gone into
the right position, at the desired OVD.
7. Remove both from the mouth and disinfect in perform.
8. Place the rims back onto the models and check that the heels of the
models are clear of each other.

Refer back to the 'shopping list' made at the treatment planning stage so that you are clear of your objectives.

Remember to select the shade and mould of teeth - this is


often forgotten! Reference should be made to previous
dentures if the patient was happy with the appearance.

Laboratory prescription

Type of articulator.
Incisal relationship.
Shade and mould of teeth.
Cusped or cuspless teeth.
Special instructions on appearance etc.

O-31

Wax Try in
Once again refer back to the treatment plan 'shopping list'. Examine the completed set-up on the articulator before
trying in the mouth. Note any discrepancies. Check balance in excursive movements. In the mouth carry out a
complete assessment of the trial dentures. Regularly, immerse the trial denture in cold water to prevent distortion.
First quickly check stability and retention before examining carefully the occlusion and freeway space. Go through
checklist as detailed below:Checks made separately (upper, then lower) :

Fit
Extensions
Retention this will not be optimal at this stage due to lack of post dam and poor adaptation of the base. If it
will not stay adequately in situ then a silicone wash impression may be required.
Stability
Position of teeth in relation to the underlying ridge and the neutral zone

Figure 1 - check that the teeth have been set up correctly in relation
to the underlying ridge

Contour of flanges (particularly the upper labial flange)


Appearance (shade and mould of teeth).
Checks made together :o Freeway space
o Occlusion
o Articulation

O-32

Figure 2 - Posterior teeth should follow the Curve of Monson

Figure 3 - The necks of the lower anterior teeth should lie directly over the ridge. The teeth may be proclined or retroclined as necessary to
achieve the incisal relationship required

Figure 4 - Check on articulator first

(A completely even arrangement of teeth usually looks unnatural. Modifications to tooth positions are frequently
required).
Remember that modification of the positions of the anterior teeth may result in occlusal interferences. Therefore
re-check the occlusion if modifications are carried out.
Carry out any corrections that are necessary. Obtain the patient's comments. Do not proceed to finish unless the
patient is satisfied with the appearance.
The clinician should draw the position of the required post dam on the model for the technician to follow. For
patients with a strong gag reflex it is sometime required to shorten the posterior border of the denture, this would
mean that the post dam is removed and have adverse consequences for retention. In those cases it is often wise to
have the denture constructed with a secondary dam should that be needed.
Written and verbal instructions on denture wearing may be provided at this visit so that the patient has time to
assimilate the information before the dentures are fitted.

O-33

Fitting the dentures


Check the finished dentures for any sharp edges, acrylic 'pearls', or excessive undercuts on the impression surface.
Insert each denture separately and check on fit and comfort. Check occlusion in the mouth.
With partial dentures occasionally the denture cannot be seated because acrylic has been processed into an
undercut area on the model; this is due to inadequate blocking out of the undercuts. If this is the case look to
identify a fulcrum of rotation by rocking the denture backwards / forwards or side to side. Once the area of fulcrum
has been identified use occlude spray to identify the exact area where the denture is being prevented from
seating.
Check the seating of any metal components if present such as clasp, rests and connectors
Upper denture alone;

Check for retention and stability as previously described


Check lip support and incisal level
If there is an anterior flange check that the border is not too bulky by gently running your fingers down the
patients cheek and onto the top lip feeling for the border of the denture as you go
Check the occlusal plane is parallel to the interpupillary plane and alar-tragal plane

Lower denture alone;

Check the stability


Check that it is in the neutral zone

Both dentures together;

Check the OVD, RVD and freeway space again


Check that the teeth meet simultaneously on both sides of the mouth Hold the lower denture firmly in
place and guide the patient into their RCP position feeling for any premature contacts, slides or rocking of
the denture as they bring the teeth into RCP
Check that any natural tooth-to-tooth contacts that you have been working to are still present

Carry out any necessary adjustments until:


a)
b)
c)
d)

The occlusal pressure on both sides of the mouth is the same.


The occlusal contacts indicated by articulating paper are primarily on the premolars and first molars
Heavy contacts distally or anteriorly should be eliminated as these may cause tipping of the denture.
Some lateral and protrusive movement is possible without cuspal interference causing displacement of the
dentures.
e) If there is a significant occlusal discrepancy, so long as there is a successful aesthetic result the posterior
teeth can be ground off leaving the denture base and record rims made at chairside to re-record the
occlusion for a repeated wax try in at the next visit.

Check..
Have I given the patient a good start by ensuring that:a)

Each denture is comfortable


O-34

b)
c)

The dentures are occluding evenly? Simultaneous bilateral contact at the correct OVD and in the
retruded arc of closure
I have given clear instructions to the patient on denture care?

Open bite in canine region due to premature contacts


posteriorly, these will require a significant adjustment of
the posterior teeth until the upper and lower canines are
able to come into contact.

If the dentures have been sufficiently satisfactory then it is OK to dispose of any laboratory work associated with the
case. The laboratory tickets used during the case should be inserted into the patients records along with the Medical
Devices Statement. A copy of the Medical Devices Statement should also be given to the patient.

For acrylic

Prosthetic Burs

Black Rubber
For coarse finishing

White Rubber
For fine finishing / polishing

Pink Stone
For gross adjustment

Green Rubber
For coarse finishing

Blue Rubber
For Fine finishing / polishing

For metal frameworks

Acrylic Bur
For gross adjustment

O-35

Advice to the patient

Insertion and removal of denture. The patient must be taught the correct way to handle the denture.
Vulnerable components must be pointed out.
Repeat instruction in oral and denture hygiene.
Stress the importance of these factors.
The following points are mentioned in the written instructions to be given to the patient, but they must also
be given verbally:Cleaning rinse after each meal, brush at night and soak in water overnight. Once or twice a week soak in
proprietary cleaner.
Eating get used to the new dentures by making food easier to eat smaller mouthfuls, easy to chew
foods.
Wearing at night for first couple of weeks, then should leave them out. Should patients not feel
comfortable with removing dentures at night they should ensure that there is a period of the day where they
leave them out and should keep them meticulously clean. Patients with denture stomatitis should always
remove the dentures at night.
Pain try to persevere if mild, if severe leave the dentures out and re-insert them some hours prior to their
review appointment to help identify sore areas.
The advice to the patient should be given earlier in the course of treatment and reinforced when the
dentures are fitted.

Denture Cleansers
The patient should rinse their dentures after each meal and brush clean each morning and night. Twice per week the
patient should use a proprietary denture soak cleanser. The manufacturers instructions should be followed exactly.
A common mistake patients make is to use very hot water when mixing up the cleanser; this could lead to bleaching
of the denture base in time.

Denture Fixatives
Denture fixatives are not a permanent alternative to having properly constructed dentures. Patients should not rely
on them for daily use, but there is evidence that even well fitting, well-constructed dentures can be more
comfortable and the patient have more confidence in social situations if a small amount of fixative is used.
In recent years the problem of zinc poisoning due to excessive use of denture fixatives has come to light, with
symptoms including balance and walking affected because zinc affects the nervous system.
Patients should be educated to use zinc-free fixatives and to use the correct amount.

Figure 5 - Fixative indicates that it is "Zinc Free"

Figure 6 - the correct amount of fixative to use

O-36

Review
Obtain the patient's comments and carry out a thorough examination of the denture-bearing tissues and dentures.
Always re-check occlusion. It is essential that an accurate diagnosis is made of any complaint. Adjust dentures
accordingly. Even if there are no complaints, the tissues must be inspected. Also, check the cleanliness of the
dentures. Arrange further appointments if necessary.
The patient should be reviewed at least every 12 months. This is to check that the dentures are still satisfactory, that
no pathology (such as denture hyperplasia or denture stomatitis) is developing and for the patients annual oral
cancer screen.
THE WELFARE OF YOUR PATIENT IS YOUR RESPONSIBILITY FOR THE DURATION OF YOUR STAY AT THE DENTAL
SCHOOL.

Figure 7 - Traumatic ulceration

Figure 8 - Trauma due to a deep post dam

The patient should be asked for comment on the first week of wearing the dentures.
A history must be taken of any concerns.
Subsequent examination must be directed to diagnosing the cause of the concerns.
Whether or not there are any problems the denture-bearing tissue must be examined and the occlusion must be
checked. Any inflammation of the denture-bearing tissues, which is not related to the border area, is most likely due
to occlusal causes. Therefore a careful inspection must be made of occlusal contact in intercuspal position and
excursive movements, and the necessary adjustment made. The impression surface of the denture must not be
'eased' empirically. A check must be made on the patient's oral and denture hygiene using the techniques already
described.

O-37

Immediate Dentures
Immediate dentures may be prescribed when it is considered desirable to copy a patients existing tooth arrangement
or we do not wish the patient to wait any length of time following extractions before the new denture is constructed.
The disadvantages of immediate dentures are extensive. They do not allow a try in procedure for teeth that are
being extracted, we are fitting dentures over an area that is numb and possibly inflamed due to the extraction so
assessing fit is difficult. Rapid change of ridge shape following extraction can make the dentures become rapidly ill
fitting.
At the institute we would like patients receiving immediate dentures to be reviewed within 24 hours of the dentures
being fitted and for that period of time the patient should be instructed not to remove the dentures unless they
need to control bleeding.
The stages of denture construction should be followed as the previous sections describe, but at the fit appointment
an appointment should be made in the locals department as well as in the restorative clinics.
Immediate additions it will be necessary to take the patients dentures away from them for a period of time while
teeth are being added. The timing of this will need to be coordinated with a laboratory technician as well as the
patient to identify the most suitable day and time frame for this to occur.

O-38

Copy dentures
Introduction
Despite a loss of retention and stability some dentures are surprisingly well tolerated and controlled by the patient.
This control is due to the effect of the oral musculature on the polished surface of the denture. The patient has
adapted to the shape of the polished surface and it is advisable to retain this shape if successful replacement
dentures are to be constructed. This is particularly relevant to the complete lower denture where muscular control
through the polished surface is so important.

Indications
General indications for the use of the copy denture technique are: 1. Previous satisfactory complete dentures (i.e. patient concerns are of recent onset). This is particularly relevant to
the elderly patient. E.g. occlusal wear.
2. Immediate dentures (The position of the original teeth are known).
3. Chronic denture patients - patients who have had many sets of dentures made without satisfaction, it is better to
make adjustments to a copy of their best previous denture, to avoid the risk of making matters irreversibly
worse.

Procedure
Clinical stage 1 - Assessment of patient and dentures.
Success of copying complete dentures is dependent on a
thorough examination and diagnosis. This will allow a
treatment plan to be designed which pinpoints the changes
needed to overcome the patients concerns.

Clinical stage 2 - Laboratory silicone putty is used to record


impressions of the existing dentures. Load the first mix of
silicone putty into an upper perforated box tray. An upper
tray should be used when copying upper and lower
dentures.

O-39

Insert the denture (teeth first) and shape the silicone so


that its edge is flush with the border of the flange.

Smooth the surface and, when set, cut three locating


notches.

Apply petroleum jelly as a separating medium. Apply to


silicone only, dont smear the denture.

Prepare a second mix of putty. Take a small amount and


push it into the deepest aspects of the ridge of the
denture.

O-40

Add the remainder, ensuring that putty has been pushed


into the locating notches. When the putty has set, open the
mould, remove the denture and inspect the mould surface.
To copy a denture with a cobalt chromium palate, please
seek advice from your tutor.

Lab stage 1 - Wax teeth and cold cure acrylic bases are
poured into the moulds.

Clinical stage 3 - The bases are tried in the mouth and the
occlusion recorded.
If the occlusal vertical dimension requires increasing, wax is
added to the occlusal surface of the teeth prior to
registration.
It is necessary to take a shade and mould of the teeth at
this stage.

The occlusion is registered using Blu-mousse.

O-41

Lab stage 2 - The bases are articulated on an average


value articulator.

The teeth are then set to replicate the position of the


original teeth. To enable this the technician will
remove the wax teeth one at a time and set the acrylic
teeth in position. Any alterations to tooth position (if
the occlusal height is increased) must be indicated to
the technician.

Clinical stage 4 - The trial dentures are tried in the mouth


and the normal checks completed.
If satisfactory then impressions are taken in the denture
bases to improve the fitting surface.
Prior to recording the impressions: 1.

Any undercuts must be removed.

O-42

Underextention of the bases can be corrected with


greenstick tracing compound.
3. Perforate the tray especially towards the anterior
of the palate and the labial flange
2.

4.

Adhesive must be applied to the fitting surface and to the borders of the denture.

It is essential that the denture be fully seated to avoid


displacement of the anterior teeth or increase to OVD

5.

The impression is taken using a light bodied


silicone. During impression taking it is important
that, once border moulding is complete, the teeth
are brought into occlusion. Once the impression
has been removed check that the covering of
impression material is thin within the denture
base. If it is too thick this will affect the occlusion
and may obliterate the free way space.

O-43

6.

You will need, at the end of this visit, to prescribe


the position of your post-dam. [N.B. If the loss of
fit of copies has been significant an impression can
be taken at stage 2. This ensures that the occlusion
is recorded using stable and retentive copies. The
impression material is left in situ for the
subsequent stages].

Lab stage 3 - The lab will cast and process the dentures

Clinical stage 5 - The fitting and review of the dentures is the same as with the conventional denture construction
technique.

O-44

Prosthetics
Reline / Rebase.............................................................................................................................................. O-45
Laboratory reline / rebase............................................................................................................................ O-45
Chairside reline............................................................................................................................................. O-47
Soft lining materials...................................................................................................................................... O-48

Reline / Rebase
When the fit of a denture has deteriorated to an unacceptable degree and you are certain that the impression
surface of the denture is the cause of the complaint, re-lining or re-basing may be the treatment of choice.
Relining should not be undertaken where there is; a lack of freeway space, lack of balanced occlusion / articulation,
or where the teeth lie outside the neutral zone.
An outline of the clinical procedure follows:Check that there are no deflective occlusal contacts, and there is sufficient freeway space to allow for the addition of
material.
Adjust the borders of the denture to correct over or under-extension for laboratory relines, under-extension can be
corrected by adapting the borders of the existing denture with green-stick.

Figure 1 - Denture requiring reline

Figure 2 - Borders adapted with greenstick

The reline can be carried out at the chairside or in the laboratory. The advantage of the laboratory reline is that a
heat cured material can be used which is stronger also the denture can be rebased which means that the palate of
an upper denture is not made unnecessarily thick as can occur during relining. There is also more control over the
reline material the reline impression can be checked to see if the denture has been correctly seated, this is not
possible with chairside relines. Chairside relines have the advantage that the patient will not be without the denture
for any protracted period of time.

Laboratory reline / rebase


Remove all undercuts in the acrylic on the impression surface to allow the denture to be subsequently removed from
the cast.

O-45

Figure 3 - Undercuts removed from acrylic and greenstick

For upper dentures perforate the palate with a few holes made with a small acrylic bur

Figure 4 - Palatal perforations

Figure 5 - Palatal perforations

Apply silicone adhesive if using silicone impression material.


Coat the impression surface of the denture with an even layer of a low viscosity silicone impression material and
relocate the denture as accurately as possible in the mouth. To ensure there is no disturbance in occlusion, ask the
patient to close the teeth gently together in the intercuspal position. Ensure that the occlusal vertical dimension is
not increased to an unacceptable degree.
The instructions to the laboratory should indicate that either a reline or rebase is required. Remember to prescribe
your post-dam. Normally a heat cured material is used but it is wise to specify this on your prescription.

Figure 7 - Rebase

Figure 6 - Reline

The difference between relining and rebasing. New material that has been added is represented in green

O-46

Chairside reline
Use TOKUSO rebase material

Figure 8 - Tokuso Rebase Material

Run an acrylic bur across the impression surface of the denture to be relined to remove the outermost surface of
acrylic material. Do the same around the borders of the denture.
Apply Rebase Aid to all surfaces to be relined. Apply a second application to the borders.

Figure 9 - Paint "REBASE AID" on all surfaces to aid bonding

Measure the correct amounts of powder and liquid according to the instructions

Figure 10 - When mixing gently fold the material to avoid the introduction of air bubbles

O-47

Mix for 10 seconds and then apply a thin layer of Tokuso to all areas of the denture to be relined.

Figure 11 - Apply to the entire impression surface

Insert into the patients mouth and ask the patient to close into intercuspal position. Gently muscle trim in the same
way as for taking an impression.
If there are no undercuts, leave the reline to fully cure in the patients mouth (approx 8 minutes) if there are
undercuts remove during the rubbery phase (after approx 3 minutes) and leave to fully cure on the bench top.
When fully hardened trim and polish.

Soft lining materials


There are two types - Short term and Long term.
The materials used are either applied at the chair side or are processed in the dental laboratory.
Short term
Indications
1. Tissue conditioning prior to taking working impressions
2. Functional impressions
3. Temporary reline of immediate dentures or following oral surgery
4. Treating denture stomatitis, where a lack of fit of the denture is a causative factor
5. Neutral zone impression techniques
6. Diagnostic aid
Example of materials
iuyf

Material

Constituents

Viscogel

Poly (ethyl methacrylate)


Ethyl alcohol
Dibutyl phthalate

O-48

Coe Comfort

Poly (methyl methacrylate)


Ethyl alcohol
Dibutyl phthalate
Zinc oxde undecylenate
Coe Soft
Poly(ethyl methacrylate)
Di-n-butyl phthalate
Benzyl salicylate
Ethyl alcohol
Viscogel and Coe Comfort are both considered to be tissue conditioners, very soft with a short clinical life span. They
should be used as a temporary relief for a patient with acute denture problems due to trauma for example at early
review following the provision of an immediate denture. Coe Soft is a longer term temporary material that will last
for several months and can help diagnose the cause of a patients denture problems and assess the suitability for a
permanent soft lining.
Clinical Technique
All the short term resilient materials are applied at the chair side to the existing denture. When mixed the material
should be applied to the entire fitting surface of the clean dry denture. The denture should be inserted and after
border moulding the teeth brought into occlusion. Once the material has gelled it can be removed from the mouth
and any excess material removed with a scalpel. Always refer to individual manufacturers mixing guides.
Patient maintenance
A brush should not be taken to the material, and denture cleansers must be relied upon. However, many of the
peroxide cleansers will cause surface damage.
Long Term
Indications
1)
2)
3)
4)
5)
6)

Atrophic mucosa
Knife edge alveolar ridge
Superficial mental nerve
Extensive bony prominence (where overlying mucosa is often very thin)
Congenital/acquired oral maxillofacial defects
Parafunction

Examples of materials
Material
Molloplast B
Coe Super Soft
Clinical technique

Constituents
Poly (dimethylsiloxane)
Acryloxyalkylsilane
Long chain acrylic
polymers and monomers, plus plasticisers

Molloplast B and Coe Super Soft are added to the denture in the laboratory. To enable this an impression is required.
This is taken in the denture normally using a light bodied silicone material. Prior to recording the impression, the
border extension of the denture can be modified with greenstick; any undercuts should be removed. It is important
that when recording the impression, the teeth are brought into occlusion once border moulding is complete.

O-49

Silicone is the preferred material as it remains soft permanently and requires less thickness than the acrylic
materials, it is also an elastic material whereas the acrylic materials are visco-elastic. It is however inert and requires
a bonding agent to adhere to the
denture base.
Although classed as long term, these
materials generally have a life span of
six months to two years, and often fail
due to debonding or candida infestation
in the case of silicone materials, or
hardening due to loss of plasticiser for
the acrylic materials.
Soft liners should be considered a last
resort for denture problems or for
patients who have previously been
satisfied with a soft liner and are keen
to retain that feature.

Figure 12 - Denture with permanent soft lining

O-50

Aide Memoirs
Aide Memoirs .................................................................................................................................................... O-51
Evaluation of the patient and dentures ....................................................................................................... O-51
Primary Impressions ..................................................................................................................................... O-52
Secondary impressions................................................................................................................................. O-53
Recording the occlusion ............................................................................................................................... O-54
Wax try in ..................................................................................................................................................... O-56
Fitting the dentures ...................................................................................................................................... O-57
Partial denture design .................................................................................................................................. O-60
Essential reading .................................................................................................................................................. O-61

Evaluation of the patient and dentures


The history and examination process should occur as for all patients, but with the following items needing further
consideration for denture patients.
Stage

Criteria to evaluate

History

Take a full history as for any patient, with special attention to denture
problems, a denture wearing history and the need for replacement of teeth

As per usual examination, with special reference to;


Examination

Extraorally lip support, appearance of teeth (including midlines), OVD,


speech
Intra-orally look at the denture bearing areas and amount of saliva

Dentures

Examine each denture for retention and stability, look at the occlusion

Diagnosis

Formulate a diagnosis of the patients problems, if there are unsatisfactory


dentures create a list of faults that require correction

Treatment plan

Include a plan to correct all of the items identified in the diagnoses

Recall

Check the laboratory handbook to find out how long will be needed between
each clinical stage. Give the patient an idea of how many appointments of
what time period to expect the treatment to take.

O-51

Primary Impressions
Stage

Criteria to evaluate

Select appropriate
stock tray

Check that the tray can be inserted and has room inside to
accommodate the impression material

Tray modification

Fill in edentulous areas with impression compound or silicone putty,


border moulding to prevent distortion of the sulcus.
Ensure adequate extension over all standing teeth and into any
sulcus where a flange or connector may need to extend

Adhesive

Apply adhesive to all areas and allow to dry for 2 minutes

Impression taking

Using alginate take a full impression, remembering to border mould


All teeth and edentulous areas included
No significant air blows that could affect surveying of models
Tongue not trapped beneath impression

Evaluation of the
impression

Material has been allowed to flow into the maxillary labial sulcus by
pulling the lip out as the impression was placed
Impression is adherent to the tray
Areas where the tray or modifying material are showing through the
alginate are not important for primary impressions, unless the tray
has not been able to seat adequately due to catching during
insertion
Impression marked to indicate extension of desired special tray
(2mm short of full depth of recorded sulcus on inside of tray) and
position of stops

Laboratory
prescription

Impression disinfected and adequately packaged


State what type of appliance is required
Indicate that it has been disinfected
Written description of special tray required

O-52

Secondary impressions
stage

Criteria to evaluate

Adequate spacing as prescribed

Evaluation of tray

Over extension corrected


Underextension corrected with green / pink stick
All denture bearing area accurately recorded
Functional depth and width of any sulcus into which a flange or other
component of the denture will extend recorded

Evaluation of
impression

Stops may show through the tray indicating that it has been fully
seated

Small air blows not occurring on abutment teeth that can be easily
filled in are acceptable

Impression is firmly adherent to the tray


Impression marked with indelible pencil to show the limits that the
model should be trimmed (2mm from full depth of recorded sulcus on
outside of impression)
Adequate disinfection and storage
Laboratory
prescription

Design for framework if required clearly drawn


Design of record rims and bases for the rims included

O-53

Recording the occlusion


Stage

Notes

Upper alone
Try in and check for
o Discomfort
o Overextension
o Retention

Wet wax rims under cold tap and insert.


Press firmly into place
Ask patient if any discomfort
Carry out muscle trimming and facial movements whilst holding in
place to feel for displacive forces
Reduce borders if necessary
Look at naso-labial angle ~ 90-110

Lip support

Incisal level

Look at philtrum
Feel top lip for adequate but not too much support
Look at previous dentures if any
Approx 1mm showing with lip at rest
Using Foxs plane guide

Horizontal plane

Parallel with inter-pupillary line


Using hot plate
Occlusal plane
Buccal corridor

Parallel with ala-tragal plane


Using hot plate
Wide grin should show some space between rims and cheeks

Continue in the next page

O-54

Stage

Notes

Lower alone
Check fit

Measure RVD

Adjust for tongue space

No discomfort
No over extension
stable
Patient upright
Neck straight
At rest
Lips closed
No tone in facial muscles
Posterior teeth should be directly over the ridge
Should be in neutral zone i.e. not being displaced

Upper and lower rims in together


Retruded position
Adjust for simultaneous
contact
Meet at correct OVD
Mark on centre line
Score in premolar region
Notches in upper and
lower rims
Apply adhesive
Blu mousse
Seal blocks together

Hold lower rim in place whilst guiding jaw into retruded position
Asking patient to feel back of upper record block with tip of tongue can
help
Watch during closure that heels of rims dont contact
Feeling the rim as it closes, feel which side meets first
Adjust as necessary until both sides meet simultaneously
Take 3mm away from RVD reading
Add or remove wax from lower using hotplate
Look straight at patient, not from the side and mark line on upper rim
coincident with centre of patients face using wax knife
Use wax knife to score a line between upper and lower rims, to use as
check mark later
To aid repositioning of blu-mousse if rims come apart later
Remove from mouth and apply silicone adhesive to upper and lower rims
Replace in mouth, try to keep dry
Squirt blu-mousse over and behind pillar of lower, guide patient into
retruded contact position, keeping lower rim held firmly down and hold
there till it sets
Remove from mouth
If not firmly sealed by blu-mousse use small amount of melted wax to seal
rims together

Stage

Notes

Disinfect

10 minutes in perform bath (only on clinic)


Using shade guide, match to existing dentures or choose shade
appropriate to age of patient and patients wishes
Three basic shapes, rounded, tapering and square
Can use photographs of patient when they had teeth if no existing
dentures
Size based upon intended position of canines
Include all details necessary for wax try in to be constructed

Choose shade
Choose mould
Laboratory prescription

O-55

Wax try in
Stage

Criteria to evaluate
Quality of wax work no rough / sharp areas,
Fit on cast
Presence of undercut

Prior to seeing
patient

Extension upper
Extension lower
Balanced occlusion
Correct position of teeth over ridge

Try in
Check comfortable
Retention (will not be optimal due to lack of post dam and
Evaluate upper

poorly adapted wax / base)


Stability
Base extension
Lip Support

Aesthetics of
upper

Occlusion
Evaluate lower

Centre line
Incisal level showing during smiling
Horizontal plane (Inter-pupillary)
Alar- Tragal
Stability
Neutral Zone / Position of lower teeth
Bilateral contacts in RCP
Balanced articulation

Evaluate
together

Centre lines coincident


Speech
Occlusal Vertical Dimension
Freeway space

Aesthetics
Laboratory
Prescription

Patients opinion on shade, shape mould and setup


Any special materials requirements
Prescribe post dam

O-56

Fitting the dentures


Stage
General appearance

Impression surface

Polished surface

Notes

Check original prescription and quality are correct

Check:
o Fit
o No sharp, rough or undercut areas
o Extension
o Border region to depth + width of sulcus
o Base to extend:
post dam with upper
pear shaped pads with lower
o Remove sharp, rough or undercut areas
o May need to use disclosing paste
o Ensure dentures can be inserted and removed without
painful symptoms
Check:
o Smooth
o Comparisons/Differences with any existing sets

In-situ (Separately) - Check upper first, then lower

Retention

Stability

Base extension

Neutral Zone

There should be resistance to displacement with the upper, if not


then most likely due to lack of a border seal resulting from:
Under-extension
Inadequate width of flange
Poor fit
Ineffective seal at posterior margin
Retention of lower will be less than the upper
At fit stage muscular adaptation will also influence retention
It may take the patient several weeks to develop this
Unless significant problems best to review after 1 week
May require reline or re-make if problem persists
Should be <2mm upper and lower
As with retention, unless significant problems best to review after
1 week
May require reline or re-make if problem persists
If overextended correct by reducing offending flange
If under-extended review after 1 week
May require reline or re-make if problem persists
Lower denture should remain in place when mouth is half open
and tongue lies just behind the lower anterior teeth.
If problems are minor review after 1 week
Significant problems may necessitate re-make or repositioning of
the teeth, in which case consult the laboratory technician
Continue in the next two pages
O-57

In-situ (together)

Occlusion

Appearance

Check:
o Initial contacts
o Ask patient to slowly close together until teeth
meet in first contact
o Ask patient which upper and lower teeth meet first
o Assess occlusion utilising:
o Vision
o Patient perception
o Articulating paper
o Visually detect:
o Deflective contacts
o Slides
o Patient perception provides excellent guide to location of
problems
o Articulating Paper check:
o Use different colours for lateral and intercuspal
contacts
Adjustments should be made until:
o Occlusal pressure on both sides of the mouth is
the same
o Occlusal contacts are primarily on the premolars
and molars
o Heavy contacts distally or anteriorly should be
removed as they can cause tipping of the denture
o Some lateral and protrusive movements are
possible without cuspal interference
Check OVD
o Insert lower measure RVD
o Insert upper measure OVD
o Assess Freeway space
o If minor problem review after 1 week but if significant
discrepancy may require re-make
Check:
o Appearance of patients lips when in occlusion
o Speech (get patient to count from 60-70). If difficulty
noticed forming the letter s then reassess OVD
Dentist in collaboration with patient should check prescription:
o Shade
o Mould
o Size
o Orientation of occlusal plane
o Position of centre line
o Lip support
o Appearance during function
Overall patient should be happy with the appearance

O-58

o
o
o
o
o
o
Denture Hygiene and
advice

o
o
o
o
o
o
o

Highlight limitations of dentures


Verbal and written instructions
Soft diet for the first few days
Friends and relatives may notice changes this is normal
particularly if significant changes have been made
Hyper-salivation and speech problems may occur but
should settle after a few days
If soreness develops which is minor patient should persist
with denture until review stage
If soreness is extensive remove dentures, replace with
old dentures, and insert new dentures a few hours before
review
Remove dentures before sleep with exception being the
first 2 weeks
Use soap and water to clean dentures with a soft brush
Always follow manufactures instructions if denture
cleansers are used
Review in 1 week
Keep laboratory prescription in notes
Give Medical devices statement to patient and copy in
notes with statement that this has been carried out.

O-59

Partial Denture Design


Identify missing teeth; decide which need to be replaced. Place an X through the
teeth not present and not being replaced.
1.Saddle
Outline the full extension of the saddle area where support is needed and to indicate
flanges.
Suitable positions and number of rest seats included (tooth surface closest to space for
bounded saddle and tooth surface furthest from space for free end saddle.
2.Support

Clearly show on the diagram and grid the positions on teeth where rest seat
preparation is to be carried out,
Identify usable undercuts and provide details of how to modify teeth if there are no
suitable undercuts where needed.
Plan guide planes to optimise retention- and list on guide plane tooth chart.

3.Retention

Appropriate number of clasps used


Appropriate design of clasps: molars use occlusally approaching 3-arm or ring clasps,
premolars and canines use gingivally approaching clasps.
Retentive clasp arms on tooth surface, identified by an arrow head.

4.Reciprocation/
Bracing

Reciprocation should be provided for each retentive clasp used either with a
reciprocating arm (if guide plane prepared) or appropriate extension of minor or major
connector.
Suitable design of major connector and clearly written on form

5.Connector

6.Indirect Retention

Suitable extension of major connector, allowing 3mm of gingival clearance where


possible
Indirect retention considered and appropriate
Patient and Clinician details entered correctly

7.Laboratory
Prescription

Prescription clear and legible with tooth charts correlating with diagram
Overall design would be functional

O-60

Essential Reading
Prosthetic Treatment of the Edentulous patient. Basker, Davenport, Thomason
Davenport J C, Basker R M, Heath J R, Ralph J P & Glantz P O. A Clinical Guide to Removable Partial Dentures. British
Dental Journal Publications 2000.
Davenport J C, Basker R M, Heath J R, Ralph J P & Glantz P O. A Clinical Guide to Removable Partial Denture Design.
British Dental Journal Publications 2000.

Paul Franklin
Senior Clinical Teaching Fellow
University of Leeds
O-61

Periodontology
A periodontal handbook is available with a more detailed explanation of the equipment and techniques we
employ. The following is a brief guide for patients attending cons or pros sessions.

Restorative patients and periodontal therapy .................................................................................................... P-2


Periodontal aspects of the restorative History, examination, diagnosis and treatment plan ................................. P-2
History ..................................................................................................................................................................... P-2
Examination of new patient.................................................................................................................................... P-3
Diagnosis ................................................................................................................................................................. P-3
Treatment plan ....................................................................................................................................................... P-4
Periodontal indices...................................................................................................................................................... P-5
Basic periodontal examination (BPE) ...................................................................................................................... P-5
Plaque free scores (PFS).......................................................................................................................................... P-5
Marginal Bleeding free scores (MBFS) .................................................................................................................... P-6
Probing pocket depths (PPD) .................................................................................................................................. P-6
Bleeding on probing (BOP)...................................................................................................................................... P-6
Mobility ................................................................................................................................................................... P-6
Recession ................................................................................................................................................................ P-6
Furcation involvement ............................................................................................................................................ P-7
Suppuration ............................................................................................................................................................ P-7
Periodontal monitoring ............................................................................................................................................... P-7
Periodontal recall and maintenance / supportive therapy ....................................................................................... P-7
Oral hygiene (plaque control) instruction .................................................................................................................. P-8
Tooth brushing instruction ..................................................................................................................................... P-8
Denture hygiene ..................................................................................................................................................... P-8
Smoking cessation counselling ................................................................................................................................... P-8
Scaling .......................................................................................................................................................................... P-8
Ultrasonic and sonic scaling .................................................................................................................................... P-8
Use of local analgesia in the treatment of periodontal disease ............................................................................. P-8
Use of systemic antibiotics ......................................................................................................................................... P-9

P-1

Restorative patients and periodontal therapy


The majority of Periodontology patients either under treatment or being seen by the student for maintenance and
review appointments, will continue to be seen by the student on the Restorative Clinic. The transfer of
Periodontology patients to the Junior Waiting List in Periodontology for more junior students may be possible if
Periodontology Waiting Lists permit. This must be discussed and arranged with a member of the Periodontology
teaching staff.
New patients taken off Waiting Lists by students in the Restorative Clinic or transferred from graduating students
should routinely have a periodontal assessment based on the methods adopted in the Periodontology Clinic.
Periodontal therapy should be undertaken BEFORE embarking on Conservation or Prosthetic work.

Periodontal aspects of the restorative history, examination, diagnosis and


treatment plan
The following notes are intended to highlight some important and relevant considerations for Restorative tutors to
guide the student in his / her history, examination and treatment plan and should supplement teaching from the
other limbs within Restorative Dentistry.

History
Past medical history

Drugs: certain drugs are associated with gingival enlargement:


o Phenytoin (Epanutin) for epilepsy.
o Cyclosporin (immunosuppressive for prevention of organ rejection after transplants - check also the need
for antibiotic cover for these patients).
o Nifedipine (Adalat / Procardia) and other calcium channel blockers (these mainly lower blood pressure)
most common therapeutic indications include hypertension, angina, arrhythmia, migraines and some
circulatory conditions.
Diabetics: poorly controlled diabetics may be more susceptible to periodontal disease.
Smokers: this is a risk factor and patients should be counselled about effects on the periodontium and
records kept (for medico-legal reasons!).
Be aware of recent research on the effects of periodontal disease on general health in particular cardiovascular disease, low birth weight babies.

Dental history
The student should check if the patient has had any periodontal treatment before, whether plaque control advice
has been given and if so of what nature e.g. has tooth brushing instruction been given? - if so was it demonstrated in
the mouth or just discussed?.

Social history
This should include an outline of how and how often patients brush their teeth and whether other aids are used.
Any habits such as smoking and relevant dietary factors should be noted here.

P-2

Examination of new patient


Oral hygiene status: A subjective opinion of the oral hygiene status should be made. This should be based on
quantity and distribution of soft deposits and particular problem areas should be highlighted.
Calculus: Note supragingival calculus distribution and make a subjective assessment of quantity.
Other plaque retention factors: Include overhanging restorations, appliances and caries.
Gingivae: A visual assessment of the condition of the gingivae should be made, including the colour, contour and
presence of inflammation.
Alveolar mucosa: If there are fraena or other conditions of the alveolar mucosa that may affect the periodontal
condition, e.g. recession, these should be noted.

BPE
The periodontal condition should be screened using the BPE (CPITN) assessment. A descriptive note of the presence,
quantity and distribution of subgingival calculus should be made at this stage. A WHO 621 probe should be used.
Bleeding on probing: A general note of the degree and distribution of bleeding on probing following the BPE is made
at this stage (note, the vaso-constrictive effects of smoking can reduce bleeding on probing). A thorough charting
can be performed later as part of the treatment plan .
Deep pockets, Furcation involvement and Mobility: It is helpful for the student to note teeth with very deep
pockets, obvious furcation involvement and also those exhibiting mobility which were detected during the BPE
screening process. This can be more thoroughly assessed if necessary as part of detailed chartings for monitoring.

Occlusion
Any occlusal irregularities should be noted which would include overerupted teeth, instanding teeth, locked lateral
excursions and premature contacts. The presence of periodontal fremitus (teeth exhibiting at least slight mobility
due to continuous trauma from occlusion) should be noted.

Special Tests
Radiographic findings: Where appropriate, radiographs should be taken (please consult 'quick menu - Radiographs,
for selection criteria') to assess the degree and pattern of the bone loss and the results of the radiographic
examination should be noted. Panoramic (OPT or Scanora teeth only views), periapical, conventional horizontal and
vertical bitewing radiographs may be taken.

Diagnosis
Diagnoses (according to the 1999 International Workshop for a Classification of Periodontal Diseases and Conditions
(Armitage 1999)) include:

Plaqueinduced gingival diseases (with or without other factors).


Non-plaque induced gingival lesions.
Chronic periodontitis.
Aggressive periodontitis.
Periodontitis as a manifestation of systemic diseases (to give a comprehensive list).
Necrotising periodontal diseases (cover both necrotizing ulcerative gingivitis and necrotizing ulcerative
periodontitis).
P-3

Abscesses of the periodontium.


Periodontitis associated with endodontic lesions.
Developmental or acquired deformities and conditions, including gingival recession.

Treatment plan
The proposed treatment plan should be outlined. It should be tailored to the individual patient and not an identical
catch all treatment plan the same for every patient.
Remember the three stages of periodontal therapy: Initial (cause related), corrective and maintenance.
The following are intended as a guide only:

Initial therapy

Baseline monitoring:
o Plaque free surface scores.
o Marginal bleeding free surface scores.
o Probing depth.
o Bleeding on probing.
o Suppuration.
o Mobility.
o Furcation involvement.
o Recession.
Oral hygiene instruction including toothbrushing instruction and appropriate interdental cleaning advice
with appropriate repetition during the patient's treatment as necessary.
Smoking counselling.
Management of plaque retention factors.
Scaling supragingivally and/or subgingivally indicating the specific areas to be scaled.
Root planing specifying the areas to be treated and whether local analgesia is indicated/not.
Monitoring following initial therapy.
The supervising tutor has responsibility for letters and referrals.

Corrective therapy
After monitoring the patient following the initial therapy consider the following possible courses of action:

Is further non-surgical Periodontal therapy required?


Is further non-surgical therapy with adjunctive systemic antimicrobials required?
Is further non-surgical therapy with local antimicrobial therapy indicated, e.g. Periochip?
Is periodontal surgery indicated?
Is any other corrective therapy indicated?
Maintenance / supportive therapy.
Can the patient be put on maintenance therapy and a recall appointment organised at an appropriate
interval?
Can the patient be discharged back to the GDP?

P-4

Periodontal Indices
Basic periodontal examination (BPE)
The BPE is used for individual patients and is widely recommended to screen for periodontal disease and is
recommended by the British Society of Periodontology.

Procedure
The teeth are examined with a specially designed probe, the WHO 621 probe. This probe has a ball end with a
diameter of 0.5mm which reduces potential penetration of the base of the pocket and aids the detection of calculus.
The probe has a black band which extends from 3.5mm to 5.5mm and is used to detect the presence or absence of
shallow and deep pocketing. The probe should be used with a light probing force of 25g.
All teeth in the adult patient are examined. In the child patient there is the potential for false pockets around second
molars so only index teeth are assessed: 16, 11, 26, 36, 31, 46. If pockets are detected distal to the most posterior
molars in adults care must be taken to discriminate between attachment loss and false pockets.
The mouth is divided into sextants:
17 - 14

13 23

24 27

47 - 44

43 33

34 37

8's should be excluded unless they are functioning in the position of the 7's, but separate relevant comments about
the 8's should be recorded.
The probe is walked around all teeth in a sextant. The worst clinical finding in a sextant is recorded as the code for
that sextant according to the following system:
Code 4
Code 3
Code 2
Code 1
Code 0
Code *

Pockets 6mm or more.


Pockets 4 - 5 mm.
Supragingival or subgingival calculus.
Overhanging restoration margins.
(No pockets > 3mm)
Bleeding on probing.
No disease.
Furcation, OR,
Recession plus probing depth= 7mm or more.

Patients who have BPE scores of 3 or 4 in a sextant should be assessed thoroughly, before commencing scaling, to
establish the level of periodontal disease affecting each tooth. This includes assessment of plaque, marginal
bleeding, probing pocket depths and bleeding on probing on 4 sites per tooth. Also mobility, furcation involvement,
recession and suppuration should be recorded for each site or tooth as appropriate.

Plaque free scores (PFS)


The OLeary Plaque Control Index (plaque free scores) is routinely used in the Restorative Department
(Periodontology, Conservation and Prosthetics Clinics).
P-5

The presence of disclosed plaque at the gingival margin is recorded for all teeth at 4 sites - buccal, mesial and distal
from the buccal aspect and lingual / palatal, on the Plaque Control Record sheet.
The total number of available tooth sites is calculated. This is the number of teeth present multiplied by 4 (as there
are 4 sites / tooth). The number of plaque free sites is counted. The number of plaque free sites is expressed as a
percentage of the total number of sites in the mouth. This allows the patient to get a higher score as the mouth
becomes cleaner, i.e. a higher mark for improved plaque control and tooth cleanliness.

Marginal bleeding free scores (MBFS)


This is assessed by running the Williams probe in the gingival sulcus and noting marginal bleeding up to 20 seconds
later. Bleeding indicates gingival inflammation and therefore gingivitis.
The presence of gingival bleeding at the gingival margin is recorded for all teeth at 4 sites - buccal, mesial and distal
from the buccal aspect and lingual / palatal, on the Marginal Bleeding Free Index Record sheet.
The number of bleeding free sites is expressed as a percentage of the total number of sites in the mouth again
allowing the patient to get a higher score as the mouth becomes cleaner.

Probing pocket depths (PPD)


A Williams probe is used to probe 4 sites around each tooth (buccal, mesial and distal from the buccal aspect and
the deepest lingual / palatal site). Pocket depths of 4mm or more are recorded on a pocket depth chart. Please
note: probing depths of 3mm or less should not be recorded.

Bleeding on probing (BOP)


This is performed by probing gently to the base of the pockets. It is commonly assessed after measuring probing
depths following insertion at 4 sites around the tooth - buccal, mesial and distal from the buccal aspect and the
deepest lingual / palatal pocket. Bleeding from the base of the pocket at the above sites is recorded.
Bleeding on probing assesses the inflammation of the deeper tissues rather than at the gingival margin. It cannot tell
us that attachment loss is occurring but is a useful indicator of a site that may require subgingival scaling and
subsequent monitoring. Absence of bleeding on probing is an important sign of a stable, healthy site.

Mobility
Mobility is measured after the tooth is pressed gently bucco-lingually between the mirror handle and digit using the
convention:
I = mobility of up to 1mm in a horizontal direction.
II = mobility of over 1mm in a horizontal direction.
III = II plus vertical movement as well.

Recession
This should be measured from the CEJ to the gingival margin with a Williams probe and recorded in mm. True
recession indicates apical retreat of the gingiva which occurs without an increase in pocket depth and should be
distinguished from loss of attachment with pocketing due to periodontitis.

P-6

Furcation involvement
Horizontal classification
F1
F2
F3

= horizontal bone loss of less than 3mm.


= horizontal bone loss of greater than 3mm.
= horizontal through and through involvement.

Vertical classification
A
B
C

= 1 - 3mm.
= 4 - 6mm.
= 7+ mm.

Suppuration
If pus is expressed from a pocket by gentle palpation of the wall of the pocket, this should be recorded.

Periodontal monitoring
Baseline assessment should be carried out at the start of the patient's treatment plan and should always include an
assessment of plaque, marginal bleeding, probing depth (of 4mm or more) and bleeding on probing in conjunction
with mobility, furcation involvement, recession and suppuration as appropriate. The plaque free and marginal
bleeding free surface scores should be repeated at regular intervals appropriate to the patient's needs.
Monitoring of the probing pocket depth and bleeding on probing may be carried out a minimum of six to eight
weeks after completion of root planing in that sextant (ideally eight to twelve weeks) in order to allow initial healing
of the treated area. Full healing may take several more weeks or months. In spite of this, during the six to eight
week period immediately following root planing, it is very important that students are vigilant in the detection of
non-responding sites (e.g. visible inflammation, suppuration, swelling, obvious subgingival calculus) and take
appropriate action to re-treat those sites, followed by monitoring after the appropriate interval.

Periodontal recall and maintenance / supportive therapy


When a course of treatment is complete it is important to arrange a maintenance programme for the patient. The
nature of the maintenance programme and frequency of recall visits will depend on the initial diagnosis and patient's
response to treatment.
A recall visit should include recording any problems that have occurred in the intervening period, a review of oral
hygiene practices and smoking habits and a thorough assessment of the periodontal tissues. The student should
check that the medical history is unchanged from the previous visit.
Although BPE can be used at 6 monthly intervals to make a general periodontal assessment, appropriate monitoring
needs to be undertaken. Sites of deep pockets (repeat pocket depth chart), remaining calculus and bleeding on
probing (repeat bleeding on probing index) should be identified and recorded and their treatment and/or future
monitoring formulated into a refined treatment plan. Changes in mobility, recession and furcation involvement
should also be recorded. Following monitoring at the recall visit, a treatment plan should be formulated and
maintenance periodontal treatment undertaken.

P-7

Oral hygiene (plaque control) instruction


Tooth brushing instruction
The Modified Bass Technique is most commonly recommended with the brush at 45 degrees pointing towards the
gingiva. Vibrating and overlapping strokes should be used and a systematic approach adopted to avoid missing
areas. The patient should be allowed to try any changes in brushing technique in the surgery in front of a mirror.
Adequate toothbrush instruction cannot be given on hand held models.

Denture hygiene
Denture hygiene must also be assessed if dentures are worn. The student should check whether the denture is worn
at night, how it is cared for and give advice on appropriate cleaning. Dentural is the usual cleansing agent of choice.

Smoking cessation counselling


The patient who smokes should be informed about the role of smoking in the aetiology of periodontal disease and
other oral disease. They should also be advised of the potentially poorer response to therapy that may occur if they
remain a smoker (Health Education Authority / BDA patient information advice on smoking and quitting and BDA
Fact File). This advice must be recorded in the patients notes.
The patients smoking status should be reviewed at subsequent appointments and efforts to cut down on cigarettes
or quit smoking should be encouraged.

Scaling
Ultrasonic and sonic scaling
Ultrasonic and sonic instrumentation are adjuncts to, but not substitutes for, manual scaling. The powered
instruments are indicated primarily for adult patients with gross calculus. Root planing must be completed with
manual instruments, e.g. curettes.
Tactile sensitivity is diminished with ultrasonic and sonic instruments. Therefore the tooth surface must be
examined with a WHO 621 probe during instrumentation.

Use of local analgesia in the treatment of periodontal disease


Scaling and polishing for many patients can be successfully and comfortably carried out without using local analgesia
(LA). However, subgingival scaling and root planing of a quadrant, sextant or fewer teeth may electively be
performed under LA.
If you think LA will be needed for any of the planned treatment this should be included in the student's treatment
plan and countersigned. The patients medical history must be checked.
LA is used to bring about analgesia of the soft tissues and to aid in control of haemorrhage. Less solution is needed
to achieve soft tissue analgesia than to anaesthetise the teeth. Nerve blocks are not always necessary.
Labial / buccal infiltrations combined with intrapapillary injections are generally sufficient for subgingival scaling and
root planing in the upper arch and lower anterior sextant. However the inferior dental nerve block may sometimes
P-8

be used in the mandible particularly when several teeth are to be treated in one visit and the teeth are sensitive to
cold or instrumentation. The mandibular buccal gingivae can be anaesthetised by the long buccal nerve injection.
Use of topical (surface) anaesthetic gel (e.g. Xylonor) can be helpful for some patients prior to injection.

Use of systemic antibiotics


Indications for use of antibiotics in the management of the periodontal diseases include the following:

Necrotising Ulcerative Gingivitis, where local measures have been inadequate.


Adjunctive to selected cases of Aggressive Periodontitis or selected periodontally compromised patients with
diabetes during the corrective phase of therapy.
Acute periodontal abscess where local drainage is not feasible / has not been obtained or where there is
systemic spread.

P-9

Appendix
Internal referral form .................................................................................................................................................... Q-2
Student leave of absence form ..................................................................................................................................... Q-3
Patient communication form ........................................................................................................................................ Q-4
History taking form ....................................................................................................................................................... Q-5
Treatment record continuation form ........................................................................................................................... Q-6
Plaque free and Marginal bleeding free scores............................................................................................................ Q-7
Diet history sheet .......................................................................................................................................................... Q-8
Layout of clinics ............................................................................................................................................................. Q-9
Items available from dispensary ................................................................................................................................. Q-10
Student summary sheet for preparing unit for use ................................................................................................... Q-11
Student summary sheet for cleaning the unit prior to use........................................................................................ Q-12
Needlestick and sharp injuries guidance .................................................................................................................... Q-13
Panavia F 2.0 step-by-step guide ................................................................................................................................ Q-15
RelyX Ultimate step-by-step guide ............................................................................................................................. Q-23
RelyX Unicem step-by-step guide ............................................................................................................................... Q-29

Q-1

Internal referral form

Q-2

Student leave of absence form

Q-3

Patient communication form

Q-4

History taking form

Q-5

Treatment record continuation form

Q-6

Plaque free and Marginal bleeding free scores

Q-7

Diet history sheet

Q-8

Layout of clinics

Q-9

Student summary sheet for preparing unit for use


MORNING (or 1st use of day)
SWITCH ON POWER (if necessary) Dental nurses or support staff will have already cleaned the
spittoon inserts and filters. 1 litre of water will also have been rinsed through the suction tubes
please check if you are unsure this has been completed

FLUSHING INSTRUMENT DELIVERY WATERLINES:


(Short Flush) You should always wear appropriate personal protective equipment when preparing
your unit for use
1

Press programme key D to lower chair (if necessary)


Move spittoon to right to allow view of flush holder cover

2
Remove cover and insert high speed and slow speed waterlines into two of the larger holders
(do not use the small holders at rear of holder)
3
Press programme key (bottom left on key pad) for approx 3 seconds (until signal bleep heard).
Flushing will begin (the display panel will indicate time count down). At the same time hold both 3 in 1
syringes over the spittoon and manually flush for 30 seconds.
(When flush cycle is complete HE36 will appear in display panel)
4
Return all waterlines into correct position on bracket table Replace flush holder cover and
return spittoon into position
PLEASE ASK A QUALIFIED DENTAL NURSE FOR ASSISTANCE IF YOU ARE UNSURE OF ANY PART OF THE
PROCEDURES
AFTER EACH PATIENT
1
Between all patients aspirate 1 disposable cup of water through bothsuction hoses and clean
spittoon with SANIWIPE cloth
check underneath of spittoon bowl in case of spillage (wipe if
necessary)
2

Perform short flush procedure as described above

3
Clean all surfaces, bracket table, patient chair, operating light (check it is cool), handpiece and 3
in 1 tubing with SANIWIPE cloth ( check cleaning protocol if unsure)
END OF DAY CLEANING PROCEDURES ARE USUALLY COMPLETED BY DENTAL NURSES OR CLINICAL
SUPPORT STAFF

Q-10

Student summary sheet for cleaning unit prior to use


You will find on the bracket table in each cubicle a blue micro fibre cleaning cloth to be used for the first
clean of the day. Each cloth is used only in one cubicle and then discarded. You should always wear
appropriate personal protective equipment when preparing your unit for use

To use:
Wet the cloth in the product sink (do not use the hand wash basin), squeeze out excess water, fold into
half and then half again.
The cloth should always be dampened for use. As each side is soiled the cloth should be turned to a
clean side until all 4 quarters have been used. The cloth can be rinsed again and can continue to be used
until all the surfaces of the unit have been cleaned.
Remove foot control from storage location

The unit should be cleaned in the following order:


1
All worktop surfaces and ledges (move all equipment stored on worktop e.g. sharps bin, etc - all
items should also be externally cleaned)
2
Bracket table including all exposed surfaces of delivery arm, control panel, handpiece and 3 in
1 tubings, operating light and light track arm,
3
Mobile nurses cart all external surfaces including plug cable and ledges, internal pull out shelf
(Amalgamator equipment)
4
Patient chair, escort chair, operator chair, assisting chair all surfaces (including back supports
and wheels)
5

All other exposed surfaces of the unit includes sides of spittoon and suction unit, base plate

Spittoon and cup filler, foot control

After each patient you should clean the unit using a Saniwipe cloth ( refer to summary sheet for
flushing waterlines)
If you require any assistance or advice please ask a dental nurse or clinical support staff

Q-11

PROTOCOLS FOR USING INSTRUMENT KITS IN ALL CLINICAL


DEPARTMENTS

DO NOT OPEN ANY PACKS UNTIL THE PATIENT HAS ARRIVED.

EACH PACK HAS AN INDIVIDUAL BAR-CODED LABEL FOR INSTRUMENT TRACKING. THERE WILL BE
A PEEL OFF LABEL ON THE OUTER PACKAGE ONE SMALL LABEL SHOULD BE PLACED AGAINST
CURRENT ENTRY ON PATIENT NOTES

INSIDE ALL KITS / INSTRUMENT TRAYS THERE WILL BE A PAPER TICK BOX CHECK SHEET YOU
MUST TICK EACH BOX ON THE SHEET TO CONFIRM THAT THE KIT /TRAY HAS THE CORRECT
INSTRUMENTS. THIS LIST MUST BE RETAINED
IF THERE IS A MISSING INSTRUMENT PLEASE NOTIFY THE SENIOR DENTAL NURSE or DENTAL
SUPPORT STAFF IMMEDIATELY.
AT THE END OF THE PROCEDURE EACH BOX ON THE CHECK SHEET MUST BE TICKED AGAIN TO
CONFIRM THAT THE CORRECT INSTRUMENTS ARE BEING RETURNED. THE CHECK SHEET SHOULD
ALSO BE SIGNED AND NAME PRINTED IN THE BOX MARKED SCRUB NURSE YOU SHOULD ALSO
STATE THE DEPARTMENT. THE CHECK SHEET MUST BE PLACED BACK INSIDE THE KIT/TRAY AND
RETURNED TO THE DIRTY AREA.
If kits / trays are returned to BBraun incorrectly (i.e. without check sheets or with missing
instruments), a non conformance report will be sent to the Dental Nurse Manager. This will
instigate an investigation by the senior dental nurse to establish why it has been returned
incorrectly.

SINGLE PACKAGED ITEMS (Supplementary items) e.g. amalgam gun, syringe will also have peel
off labels on outer package- at the moment there is no need to place small label on patient notes.
Used instruments should be returned to dirty area / dispensary and placed in the WIRE BASKET in
the correctly DESIGNATED BOX
HANDPIECES will follow procedure as above and be placed in a separate DESIGNATED
COLLECTION BOX
PLEASE ASK A QUALIFIED DENTAL NURSE OR THE DISPENSARY STAFF FOR ADVICE IF YOU ARE UNSURE
OF ANY PART OF THE CORRECT PROCEDURE

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Needlestick and sharps injuries guidance


Advice for dental students on clinical placements
Injuries (needlesticks) can result from needles and other sharps e.g. scalpels used
in medical procedures. Used sharps can transmit infections from the patient, in
particular the blood-borne viruses HIV, Hepatitis B and Hepatitis C. These
infections can also be transmitted by body fluid splashes on to mucosal surfaces
(e.g. eyes or mouth) or on to broken skin. The risk from such incidents is reduced
by appropriate protective clothing, for example wearing gloves for phlebotomy.
Prevention, by using needle safe devices and careful disposal of sharps is better
still!
However, these incidents do happen and are frightening and stressful experiences.
Each clinical placement should have local guidance in place on who to contact for
help following such an incident - make sure you know where to find this when you
start each new attachment.
The key actions to take are listed below:

1. First aid

Encourage the wound to bleed (dont suck it!)


Wash the wound using running water and soap
Dry the wound and cover with a waterproof plaster or dressing
Irrigate the site of a mucosal splash

2. Report the incident to your supervisor or person in charge (e.g. Senior


Dental Nurse)

3. Seek urgent medical advice even out-of-hours - if treatment is needed

it should be started as quickly as possible.

Telephone the Occupational Health Department (if available on site) to request


urgent review.
Otherwise, go to the nearest Accident and Emergency department straightaway.
Other sources of help and advice:
Infectious Diseases Department, St Jamess University Hospital, Leeds
Q-13

Contact numbers: office (working hours) 0113 206 6614, duty registrar (24 hours)
via switchboard 0113 243 3144, ward (24 hours) 0113 206 9120
Occupational Health Service, Leeds Teaching Hospitals (working hours)
Contact number 0113 206 5228
Once the urgent situation has been dealt with please contact the Occupational
Health Service at Leeds Teaching Hospitals for follow-up arrangements

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