Oral and maxillofacial surgery, radiology, pathology and oral medicine

Master Dentistry

Content Strategist: Alison Taylor

Content Development Specialist: Catherine Jackson

Project Manager: Srividhya Vidhyashankar

Designer/Design Direction: Mark Rogers

Illustration Manager: Jennifer Rose

Illustrator: Graeme Chambers

Master Dentistry

Volume One

Oral and Maxillofacial Surgery, Radiology, Pathology

and Oral Medicine

T H I R D E D I T I O N

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2013

Paul Coulthard

BDS MFGDP(UK) MDS PhD FDSRCS FDS(OS)

RCS

Professor of Oral and Maxillofacial Surgery

School of Dentistry

The University of Manchester;

Consultant in Oral Surgery

Central Manchester University Hospitals NHS

Foundation Trust,

UK;

Visiting Professor

School of Dental Medicine

Mohammed bin Rashid Al Maktoum Academic

Medical Centre

Dubai Health Care City,

UAE;

Visiting Professor

Faculty of Dentistry

Universitat Internacional de Cataluña

Barcelona, Spain

Keith Horner

BChD MSc PhD FDSRCPS FRCR DDR

Professor of Oral and Maxillofacial Imaging

School of Dentistry

The University of Manchester;

Consultant in Dental and Maxillofacial Radiology

Central Manchester University Hospitals NHS

Foundation Trust, UK

Phil Sloan

BDS PhD FDSRCS FRCPath

Professor of Oral and Maxillofacial Pathology

School of Dental Sciences

Newcastle University;

Consultant Histopathologist

Royal Victoria Infirmary

Newcastle upon Tyne, UK

Elizabeth D Theaker

BDS BSc MSc MPhil

Consultant in Oral Medicine

Dundee Dental Hospital NHS Tayside;

Senior Lecturer in Oral Medicine

Dundee Dental School

University of Dundee, UK

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This book and the individual contributions contained in it are protected under copyright by the

Publisher (other than as may be noted herein).

First edition 2003

Second edition 2008

Third edition 2013

ISBN 978 0 7020 4600 1

British Library Cataloguing in Publication Data

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Notices

Knowledge and best practice in this field are constantly changing. As new research and

experience broaden our understanding, changes in research methods, professional practices, or

medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in

evaluating and using any information, methods, compounds, or experiments described herein. In

using such information or methods they should be mindful of their own safety and the safety of

others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check

the most current information provided (i) on procedures featured or (ii) by the manufacturer of

each product to be administered, to verify the recommended dose or formula, the method and

duration of administration, and contraindications. It is the responsibility of practitioners, relying

on their own experience and knowledge of their patients, to make diagnoses, to determine

dosages and the best treatment for each individual patient, and to take all appropriate safety

precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,

assume any liability for any injury and/or damage to persons or property as a matter of products

liability, negligence or otherwise, or from any use or operation of any methods, products,

instructions, or ideas contained in the material herein.

Printed in China

v

Contents

Preface vi

Using this Book vii

Dedication xi

1 Evidence-based practice 1

2 Assessing patients 13

3 Human disease and patient care . . . . . . . . . . . . . . . . . . . . . . . . . 29

4 Control of pain and anxiety 59

5 Infection and inflammation of the teeth and jaws 89

6 Removal of teeth and surgical implantology 117

7 Diseases of bone and the maxillary sinus 147

8 Oral and maxillofacial injuries 177

9 Dentofacial and craniofacial anomalies 199

10 Cysts and odontogenic tumours . . . . . . . . . . . . . . . . . . . . . . . . 213

11 Mucosal diseases 237

12 Premalignancy and malignancy 265

13 Salivary gland disease 287

14 Facial pain 311

15 Disorders of the temporomandibular joint . . . . . . . . . . . . . . . . . . . 327

16 Radiation protection 341

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

vi

Preface

This book has been written for undergraduate and

postgraduate clinical students to help their knowl￾edge and understanding of the oral and maxil￾lofacial sciences. Our purpose is to present the

core knowledge of our specialties in an integrated

and patient-focused way. The disciplines of oral

surgery, dental and maxillofacial radiology, oral

and maxillofacial pathology and oral medicine

have been brought together to provide an under￾standing of clinical problems. We have therefore

worked together to compile chapters, although

we have each taken a lead in coordinating par￾ticular chapters (Paul Coulthard, Chapters 1,

3, 4, 6, 8, 9; Keith Horner, Chapters 2, 5, 7, 15,

16; Philip Sloan, Chapters 10, 11, 12, 13; and

Elizabeth Theaker, Chapter 14). This new edition

has been thoroughly updated since the publication

of the earlier popular text. I would like to thank

Edmund Bailey, Neil Patel, Verena Toedtling and

Oliver Tabbenor for reviewing many of the chap￾ters. Other areas of dentistry are dealt with in the

accompanying volume of this series – Master Den￾tistry Volume Two: Restorative Dentistry, Paediatric

Dentistry and Orthodontics, edited by Peter Heas￾man. We hope that the format is fresh and stimu￾lating with ample opportunity for readers to assess

their knowledge.

While this book will act as a core text for under￾graduate dental students, it will also be useful for

postgraduates undertaking a Masters degree in Oral

Surgery or preparing for the Membership of the

Joint Dental Faculties (MJDF) or Membership in

Oral Surgery examination of the Royal College of

Surgeons in the UK or international equivalents.

Paul Coulthard

2013

vii

Using this Book

Philosophy of the book

This book brings together core text from the tra￾ditional subject areas of oral and maxillofacial

surgery, radiology, pathology and oral medicine to

help readers organise their knowledge in a useful

way to solve clinical problems. We believe that this

core text of knowledge is essential reading for uni￾versity undergraduate final examination success. It

will also be of help to graduates undertaking voca￾tional training, their trainers and those preparing

for postgraduate professional examinations such as

the MJDF in the UK or international equivalent.

This book will also be helpful for those undertak￾ing university higher degrees such as a Masters in

Oral Surgery or specialist clinical training in oral

surgery leading to Membership examinations of

the Royal Colleges in the UK or international

equivalent.

During your professional education, you will be

gaining knowledge of oral surgery, oral medicine,

oral pathology and radiology, and also developing

your clinical experience in these areas of dentistry.

You may however, be anxious to know how much

you should know to answer examination questions

successfully. The aim of this book is to help you to

understand how much you should know. However,

we also believe that learning is for the purpose of

solving clinical problems rather than just to pass

examinations, we therefore, we hope to help you

to develop understanding. To ensure examination

success, you will need to integrate knowledge and

experience from different clinical areas so that you

can solve real clinical problems. If you aim to do

this, then you will be able to cope with the simu￾lated ones in examinations.

You are required to be competent to practise

dentistry upon graduation and this requirement is

directly related to how to be successful in the finals

examinations. Your examiners will expect you to

demonstrate to them that you will make sensible

and safe decisions concerning the management

of your patients. So demonstrate that to them!

Your clinical judgement may not be based on a lot

of experience but it will be sound if you stick to

basic principles. Ensure that you can take a logical,

efficient history from a patient and that you are

confident in your clinical examination. You will be

required to use your findings, together with your

knowledge and the results of appropriate investiga￾tions, to reach a diagnosis and suggested treatment

plan. Various aspects of this process are examined

in different ways, but to be successful in final uni￾versity and postgraduate examinations, you must

appreciate that there is a difference between learn￾ing and understanding. Being able to regurgitate

facts is not the same as applying knowledge and

will not help your patients.

It is important that you understand what you

would be expected to know and manage according

to your role and your particular working environ￾ment. We have therefore, been explicit about the

knowledge and skills required of those dentists

working in primary care, offering general dental

services and those working in hospital practice,

offering specialist care. There is often confusion

about the role-play in an examination, and candi￾dates attempt to avoid further questioning by stat￾ing that they would refer the patient to a specialist

rather than manage them themselves! In reality,

there are clearly some things that you must know

and others that you need only to be aware of; it is

important to know when to refer. However, even

if you are not working in a hospital environment,

you need to be able to explain to your patient

what is likely to happen to them. For instance, if

a patient experiences intermittent swelling asso￾ciated with a salivary gland, then you will need

to refer the patient to hospital for investigation,

but you also need to be able to give your patient

an idea about the most likely pathosis and man￾agement. Also, when deciding that your patient

requires general anaesthesia for their treatment,

you need sufficient knowledge to make an appro￾priate sensible referral and to provide the relevant

information for your patient, even though you will

not be providing the anaesthesia.

viii

Using this Book

Layout and contents

We have presented the text in a logical and concise

way and have used illustrations where appropri￾ate to help understanding. Principles of diagnosis

and management are explained rather than stated,

and where there is controversy, this is described.

The contents cover the broad areas of subjects of

relevance to oral surgery, oral medicine, oral and

maxillofacial pathology and dental and maxillofacial

radiology, but are approached by subject area rather

than by clinical discipline. We deliberately present

an integrated approach as this is more helpful when

learning to solve clinical problems. The artificial

boundaries of specialties does not assist the clini￾cian learning to deal with patient problems. The

boundaries of oral surgery and maxillofacial surgery

are frequently blurred and controversial around the

world! In this book, we have included all the com￾petencies of European oral surgery, surgical removal

of teeth/roots, impacted teeth, exposure of

unerupted teeth, endodontic surgery, management

of fractures of the jaws and facial skeleton, man￾agement of oroantral communication, management

of jaw anomalies, oral implantology, mucosal, skin

and bone grafts, oro/facial pain, temperomandibu￾lar joint (TMJ), biopsies, preprosthetic surgery and

salivary gland disease. We have also included areas

usually the remit of maxillofacial surgery, such as

the management of oral cancer, cleft lip and palate

and craniofacial anomalies, although in less datail.

Many of the answers to the questions in the self￾assessment sections present new information not

found in the text of the chapter, to get the most

out of this book, it is important to include these

assessment sections. While it may be tempting to

go straight to the answers, it would be more ben￾eficial to attempt to write down the answers before

turning to them, or at least think about the answers

first.

Approaching assessment

The discipline of learning is closely linked to prepa￾ration for assessment. Give yourself sufficient time.

Superficial memorising of facts may be adequate

for some multiple choice examinations but will

not be adequate when understanding is required.

Spending time to acquire a deeper knowledge and

understanding will not only get you through an

examination but will have long-term use solving

real problems in clinical practice. It is useful to dis￾cuss topics with colleagues and your teachers. Talk￾ing through an issue will let you know very quickly

whether or not you understand it, just as it will in

an oral examination!

This book alone will not get you through an

examination. It is designed to complement your

lecture notes, your recommended textbooks, past

examination papers and your clinical experience.

Large reference textbooks are of little use when

preparing for examinations and should have been

used to supplement your notes and answer par￾ticular questions during the course. Short revision

guides may have lists of facts for cramming but will

not provide sufficient information to facilitate any

understanding, and will not be enough for finals

and postgraduate examinations. Medium-sized

textbooks recommended by your teachers will

therefore, be the most useful. This book will help

to direct your learning and enable you to organise

your knowledge in a useful way.

The main types of assessment

There are many different types of assessment.

Workplace-based assessments are often used to

continuously assess clinical progress and compe￾tence and these are integrated into programmes

to assess work undertaken on a day-to-day basis.

Knowledge and understanding are usually assessed

with a range of more traditional methods includ￾ing multiple choice questions (MCQs), extended

matching questions (EMQs), short notes, essays

and oral examinations. Objective structured clinical

examination (OSCE) may be used to assess com￾munication skills, clinical skills and knowledge.

Make sure that you are familiar with the type of

assessment and look at any past examination papers

if they are available.

Multiple choice questions

Multiple choice questions (MCQs) are usually

marked by computer and are seen to be a good

method of examining because they are objective,

but they do not often check understanding. They

do require detailed knowledge about the subject.

Be sure to read the stem statements carefully as it

is possible to know the answer but not score a point

because you misunderstand the question. Calcu￾late in advance how much time you have for each

Using this Book

ix

question and check that you are on schedule at

time intervals during the examination. Find out if

a negative marking system is to be used, such that

marks are lost for incorrect answers, as this will

determine whether it is worth a guess or not when

you do not know the answer.

Extended matching items

Extended matching items (EMIs) are thought to

be valuable in assessing both the level and applica￾tion of knowledge. They may be based around a

theme, such as a diagnosis, a set of investigations

or a symptom or sign. Identify the theme, then

carefully read the introductory ‘lead in’ state￾ment. Note that an option to be matched with

each vignette or case may be used once, more than

once or not at all. On occasions, when more than

one option could be correct, choose the best option

available.

Short notes

Do not waste time writing irrelevant text. Short

note questions are marked by awarding points for

key facts. While layout is always important to allow

the examiner to identify these facts easily, a logical

approach is less important than for an essay. Give

each section of the question the correct propor￾tion of time rather than spending too long on one

part in an attempt to get every point. It is more

efficient to get the easiest points down for every

question rather than all for one part and none for

another.

Essays

Answer the number of essays requested. It is dan￾gerous not to answer a question at all and many

marking systems will mean that you cannot pass

even if you answered another question rather well.

Quickly plan your answer so that you can present a

logical approach. The use of subheadings will guide

your examiner through the essay, indicating that

you have an understanding of the breadth of the

question and score you points on the way. A brief

introduction to set the scene will produce a good

impression. Describe common factors first and

rare things later. Try to devote a similar amount of

text to each aspect of the answer. Maintain a con￾cise approach even for an essay. Finish the essay

with a conclusion or summary to draw together

the threads of the text or describe the clinical

importance.

Oral examinations

The oral examination can induce a lot of anxiety for

some people but preparation and practice can alle￾viate this. Some oral examinations include presen￾tation of a clinical case. It can be very difficult to

know how well or not you are doing, depending on

the attitude of the examiners. The examiners usu￾ally begin with general questions and then move on

to requests for more detailed information and con￾tinue until you reach the limit of your knowledge.

It is useful to have preprepared initial statements

on key subjects, which might include a definition

and a list of causes or types of pathology. This can

help you to be articulate at the start of the viva

until you settle into things.

There is frequently more than one answer to a

question of patient management and it is not wrong

to state this in an examination. To explain that a

particular area is not well supported by scientific

evidence and describe the alternative views will

be respected and appreciated. Students are often

advised to lead the direction of the viva, but in

practice this may be difficult to do. In reality, the

examiner may insist that you follow rather than

lead. Remain calm and polite and do not hold back

on showing off what you know.

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xi

Our partners and Matthew, Francesca and Imogen

Dedication

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1

Overview

Evidence-based medicine and dentistry is not new

but is not always well understood. It is a way of

thinking that should permeate every aspect of clini￾cal practice. This chapter describes this philosophy,

provides an overview of its components and pro￾vides an approach on how to make best use of the

scientific literature and the benefits of evidence￾based medicine.

1.1  Decision making

Clinical decision making is influenced by many

factors, including expert opinions, experience, expec￾tations, financial constraints and political pressures, in

addition to research evidence.

Evidence-based medicine is the explicit and judi￾cious use of current best evidence to guide health

care decisions. It integrates this best research evi￾dence with clinical expertise and patient values.

The aim of evidence-based medicine is to optimise

clinical outcomes and quality of life for patients.

This approach may be used for individual

patients, or for planning and purchasing care for

groups of patients. Patients will benefit if their cli￾nician is abreast of the latest data but he or she also

needs to be able to take a good history, carry out a

thorough examination and have an understanding of

the patients’ values and preferences.

Evidence-based medicine

Best research evidence

When working with patients, there is a constant need

to seek information before making a clinical decision

and professionals need to develop the habit of learning

by inquiry, so when confronted with a clinical question

they can look for the current best answer as efficiently

as possible. It can be difficult to find the current

answer in a large database such as MEDLINE with

over ten million references. A specialised database

such as the Cochrane Library or Best Evidence can

be a better place to start. Best-evidence resources are

growing in number and are accessible as never before.

Best research evidence is clinically relevant

research from basic science and clinical research.

Evidence-based practice

CHAPTER CONTENTS

Overview                       1

1.1 Decision making 1

1.2 Randomised controlled trials . . . . . . . . . 3

1.3 Other research methods 6

1.4 Systematic reviews 7

1.5 How to read a paper 8

1.6 Clinical practice guidelines         11

Learning objectives

You should:

• know what influences clinical decisions

• understand what evidence-based practice is

• understand the advantages and limits of using an

evidence-based approach to practice.

2

Master Dentistry

It either validates previously accepted diagnos￾tic tests, preventive regimens and treatments, or

replaces them with new ones that are more pow￾erful, more accurate, more effective and safer. The

strength of evidence from various study designs is

shown in Fig. 1.1.

Do not look at promotional brochures, which

often contain unpublished material. Ignore anec￾dotal ‘evidence’, such as the fact that a dental

celebrity is using a particular product. Do not

accept the newness of a product as an argument

for changing to it as the opposite might have a good

scientific argument.

Clinical expertise

Clinical expertise is the ability to use clinical

skills and past experience to rapidly identify each

patient’s unique oral health state and diagnosis,

their individual risks and benefits of potential inter￾ventions and their personal values and expectations.

Patient values

Patient values are the unique preferences, con￾cerns and expectations each patient brings to a

clinical encounter and which must be integrated

into clinical decisions if they are to serve the

patient. It is usual practice for the clinician to

describe the diagnosed condition or disease to the

patient and then describe the treatment available

together with the harms that the treatment may

potentially cause. To determine the patient val￾ues, the clinician could go on to ask the patient

to make a value judgement about these two, that

is, which is worse and by how much. The patient

may need to think about this or discuss it with

family members. The clinician may also describe

the outcomes of forgoing or accepting treatment.

For example, when the consultation concerns the

removal of a lower wisdom tooth, the clinician

may ask the patient to compare the distress caused

by the pericoronitis with the anticipated dis￾tress of temporary pain and swelling and possible

altered sensation. The patient should also take into

account the likelihood of future episodes of peri￾coronitis if they forgo surgery.

Benefits and limitations of

evidence-based medicine

The aim of evidence-based medicine is to improve

clinical outcomes for patients and there is plenty of

evidence that this is the case. One example is that

myocardial infarction survivors, who are prescribed

aspirin or beta-blockers, have lower mortality rates

than those who aren’t prescribed these drugs.

Another example would be the benefit of using

streptomycin for pulmonary tuberculosis as dem￾onstrated by the historic Medical Research Council

trials. These are generally regarded as the first of

the modern randomised controlled trials.

The randomised controlled trial provides the

underlying basis for evidence-based medicine and

the number of trials is growing exponentially with

more than 150 000 listed by the Cochrane Library.

However, there are limitations to evidence-based

medicine. There is a shortage of consistent scien￾tific evidence, difficulties in application of research

evidence to individual patients and barriers to the

practice of high-quality care. Some clinicians mis￾understand the philosophy of evidence-based medi￾cine and incorrectly believe that it means a loss of

clinical freedom, or that it ignores the importance

of clinical experience and of individual values,

which is not the case.

Systematic reviews and meta-analyses

Randomised controlled trials

Cohort studies

Case-control studies

Cross-sectional surveys

Case reports

STRONG EVIDENCE

WEAK EVIDENCE

Fig. 1.1 • Strength of evidence from some research designs.