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April 2020 DentalUpdate 285
Comment
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Manuscripts should be prepared following the
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a synopsis before writing an article. The opinions
expressed in this publication are those of the
authors and are not necessarily those of the editorial
staff or the members of the Editorial Board. The
journal is listed in Index to Dental Literature, Current
Opinion in Dentistry & other databases.
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Trevor Burke
Please read our privacy policy, by visiting http://
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how we process, use & safeguard your data.
Yesterday, now, or tomorrow: caries etc?
Readers will hopefully recall that, in my last Comment, I discussed a series of articles which were
published in Dental Update in 1986 which included the occasional series entitled‘Dentistry in
the year 2000’, and that some predictions made for 2000 indeed applied to 2020. However, there
were notable exceptions in the subjects covered, so I then took a look at volume 14, published
throughout 1987.
I found another rich seam of information! Among the articles of interest was one by
our Emerita Board member, Edwina Kidd, who addressed the subject – Dental caries: problem
solved?1
This might be considered to be an outrageous title for 1987, but then, it did have a
question mark! As long ago as 1987, she wrote about the increasing life expectancy of the public
(which has continued, thankfully) along with the problems that caused, and the increasing
prevalence of root caries with age, a topic which has recently received attention in Dental Update
by way of two excellent papers. She wrote, that‘although many children are caries free, there
are still some with a remarkably high level of disease’– still the same today. Edwina goes on to
describe methods for testing salivary flow rate and its buffering capacity as a means of diagnosis
of caries risk and also suggests microbiological examination for bacterial counts, given that
caries is a specific bacterial infection and that this could form part of the assessment of caries
risk. Neither of these has been widely adopted, but it seems that there remains, today, a need
for the development of a simple, readily acceptable method of assessing caries risk. Edwina
concluded that‘the profession is working in challenging times’, adding that‘the problems of
dental caries are far from solved’, and that‘academics and practitioners alike are privileged to
have the opportunity to solve them’. Nothing has changed, has it?
Another paper that caught my eye was Ted Renson’s Editorial Comment entitled
‘Funding in the NHS in the 1990s’.2
He wrote –‘…the cost of healthcare rises faster than costs in
general’. Indeed, at that time, despite an increase of 19% in NHS spend in ten years, patient care
had not improved. His suggested approach was to decentralize the system and return healthcare
to the communities that it is meant to serve. Would that have worked in the year 2000? Would
it work today? In that regard, to illustrate that the NHS funding problems still exist, the current
status of NHS dentistry will be discussed in the next issue in a paper by Martin Kelleher.
Finally, some things never go away. With the massive difficulties that the world is
facing regarding COVID-19, there were two relevant papers in Dental Update in 1987.3,4
It may
be worth adding, for young readers, that that was around the beginning of infection control in
dentistry. Prior to that, dentists practised without wearing gloves, even for minor oral surgery, a
horrifying thought today. Then I alluded to the fact that glove wearing would increase alongside
the increased incidence of diseases such as hepatitis B and AIDS, although not all infected
patients could be identified by their history. These problems have not gone away, while, at the
same time, new ones have arrived to challenge our infection control.
References
1. Kidd EAM. Dentistry in the year 2000. Dental caries: problem solved? Dent Update 1987; 14: 236–245.
2. Renson E. Funding the NHS in the 1990s. Dent Update 1987; 14: 141–142.
3. Renson E. The control of transmissible diseases. Dent Update 1987; 14: 49–-51.
4. Burke FJT, Wilson NHF. Non-sterile gloves: evaluation of seven brands. Dent Update 1987; 14: 336–339.
Post script: Many thanks to the reader who commented – Great opening comment from Trevor
Burke – finally warming to him!
Downloaded from magonlinelibrary.com by 128.240.208.034 on May 16, 2020.

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COVID-19 Considerations in Dental
Care
Enhanced CPD DO C
Abstract: COVID-19 is a disease that is causing uncertainty with the provision of dental services. The situation is rapidly changing and
dentists remain unsure on how to change practices accordingly. Formal guidance remains sparse at the time of writing, so this paper
presents matters within the practice of dentistry to be considered, as we adapt to the rapidly-changing need.
CPD/Clinical Relevance: Dentists are unsure what to do and where to look for guidance during this worrying pandemic situation. A
structured presentation of matters arising within the practice of dentistry is required for consideration in order to maximize the safety of
patients and members of the dental team.
Dent Update 2020; 47: 287–302
Samy Darwish
Samy Darwish, BSc, BDS, MFD RCS,
DipDSed, MSc, MClinDent, MRD RCS,
LLM, FDS RCS, Specialist in Oral Surgery
and Periodontology, Oral Surgery Ltd,
London, UK.
As the world prepared to celebrate a
turning over of a new leaf for a new
decade on 31st December 2019, a
low profile unwelcome guest was
introduced to the party at Wuhan City
in China named COVID-19. Not much
notice was initially taken, but the now
infamous novel disease seems to have
changed the world forever. Initially
presenting as a low-grade, flu-like
illness, it has now established itself
as a worldwide pandemic with far
reaching, severe and all-too-often tragic
consequences.
Caused by the single-
stranded RNA virus, SARS-CoV-2,
COronaVIrusDisease-2019 has now
become more infamous than its
previously known cousins, Severe
Acute Respiratory Syndrome (SARS)
and Middle East Respiratory Syndrome
(MERS). Unlike a carrier of the common
cold or influenza virus that may infect
1-2 people, an individual with COVID-
19 is likely to infect 2-3 people when in
direct contact and close proximity.1
It
does not seem to be heavily contagious
through breathing, but via contact
with droplets or contaminated surfaces
that eventually lead to introduction
to the body through mucosal surfaces
via the eyes, nose and mouth. Many
individuals may present with mild to
moderate symptoms and may even
have no detectable manifestations at
all, meaning the community may well
have a substantial number of ‘silent
super-spreaders’, some of whom may be
our patients. The only realistic method
of combatting the spread is to minimize
individual-to-individual close contact,
frequent hand-washing and sanitization,
and to disinfect surfaces stringently.
When symptomatic,
COVID-19 seems to manifest as a viral
pneumonia presenting as fever, muscle
aches and a dry cough with some
shortness of breath.2
It does not seem
to present commonly with other often
recognizable features of a respiratory
infection such as sneezing, runny nose
and tearing eyes. The highest viral
load has been found to be on mucosal
surfaces of the naso- and oro-pharynx.
By the nature of the practice
of dentistry, being in such close
proximity to patients’faces during
operative positions means that dental
healthcare workers are particularly
susceptible to catching, as well as
transferring the virus (Figure 1). In a
rapidly changing situation, patients
are looking to healthcare providers for
particular attention, but the guidance
is fluid and variable. At the time of
writing, governmental and professional
advice for dentists is particularly sparse,
as we look for guidance in adjusting
our standard operational procedures
to suit the changing environment. This
has necessitated the need to provide
structured commentary, in order to
help dentists consider the impact of the
disease on the profession and how we
should consider our practices.
Service provision
In line with the World Health
Organization (WHO) and most
governmental organizations,
community members remaining at
home when possible is the most
beneficial method of combatting the
Reader advisory: This article was written during
the emergence of the COVID-19 pandemic. As
the author states, UK and International readers
should adhere to official local guidelines
regarding the practice of dentistry during this
global crisis.
Downloaded from magonlinelibrary.com by 137.219.005.013 on April 22, 2020.

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288 DentalUpdate April 2020
spread of the disease. The government
has issued advice to hospitals to cancel
non-essential elective surgeries in order
to consolidate the workforce and make
the use of essential equipment such
as ventilators increasingly available, as
well as to limit the need for members
of the public to leave their homes. The
American Dental Association has advised
that non-emergency dental treatment
should be postponed,3
but there has
been no clear guidance as yet from the
British organizations. With this in mind,
providers may consider limiting clinical
dental services in the primary sector to
the essential management of acutely
painful conditions or those requiring swift
intervention. Examples of such conditions
may include the management of acute
pulpitis, facial cellulitis, pericoronitis,
fractured prostheses and appliances
causing trauma, symptomatic hard and
soft tissue lesions and conditions, as well as
investigations of suspicious-looking lesions.
Fractures of teeth and restorations causing
aesthetic and functional concerns may
be considered to require management of
moderate rather than immediate urgency.
Alleviating pain and disease progression
must remain amongst the responsibilities
that dental professionals aspire to provide.
Figure 1. A dentist’s operating position is so
close to the patient, putting us at risk of catching
contagious viruses.
Table 1. American Dental Association Essential vs Non-Essential Dental Procedures.
It may be worth considering deferring
management of non-urgent conditions
such as gingivitis, chronic periodontitis,
cosmetic dentistry or orthodontics. The
author does not aim to make any specific
recommendations to categorize urgency
of dental conditions but merely encourage
an enhanced level of discretion between
clinical staff and patients when considering
reasons for a dental attendance. A risk-
benefit analysis of interfering with advice
from government and our medical
colleagues in order to attend a dental
clinic should be carefully performed. The

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American Dental Association has published
a guide to dentists in categorizing dental
procedures according to how essential they
may be. This is displayed in Table 1.
The COVID-19 dental patient
Any patient with a positive diagnosis of
COVID-19 that requires dental management
should be directed to NHS 111 in order
to be managed appropriately. Managing
such patients independently and without
approval in a primary care facility is strongly
discouraged. Any individual not in PPE
should remain a safe distance of 1−2 metres
from the patient and in a well-ventilated
area.
Triage
A telephone triage procedure may be
performed by an adequately trained
member of the clinical and administration
team in order to assess vulnerability of
patients, as well as a potential threat they
may pose to members of the professional
team and other patients and accompanying
individuals in the building.
A number of vulnerable groups
have been identified as susceptible to
more severe consequences of the disease
and are therefore to be encouraged for a
higher degree of self-isolation from the
community as long as this does not cause
a substantial compromise to their medical
or dental health and general wellbeing.
These are the elderly patients, in particular
over 70 years of age, the systemically
medically compromised, in particular
the cardio-respiratory compromised and
immuno-compromised, and pregnant
patients, in particular those in the third
trimester. A careful sensitive explanation
should be provided to such patients prior
to their dental appointments to assist them
in making a risk assessment for dental
attendance, whilst also being mindful not to
eliminate or prejudice against any patient
groups regarding their access to dental care.
Patients seeking dental
appointments must also be assessed for
the risk they could potentially pose to staff
of the clinical facility and other attending
patients and accompaniers. Patients should
be asked if they have recently suffered any
fever, flu-like symptoms, or have been in
close contact with any individuals with a
proven positive diagnosis of COVID-19.
Given that the WHO has now declared
a global pandemic situation, enquiring
about recent travel to any countries or
regions considered ‘high risk’is no longer
of any particular benefit. Categorizing
countries according to risk has now been
discontinued by the NHS.
Organizing clerical facilities
Reception staff at dental practices are
normally the first point of contact for
patients. Re-designing a reception desk
to have a protruding worktop surface of
at least one metre may help achieve an
appropriate distance between a receptionist
and a patient. Whilst face-to-face contact
with patients is often necessary, there are
times when it may not be essential. Sensible
restructuring of administration facilities may
be considered. For example, a member of
the clerical team staffing the phones need
not necessarily perform this duty at the
front desk. Such duties could be performed
elsewhere in the premises, therefore
minimizing contact with members of the
public (Figure 2). Sensible allocation of
tasks to staff should take into consideration
their own susceptibilities as well as their
skill set. For example, a staff member with
an underlying cardio-respiratory condition
could be deployed to manage the phones
in an isolated area, away from exposure to
members of the public.
In line with the government’s
‘work from home if possible’policy,
members of the dental team, particularly
those performing clerical tasks could
consider working from home. Techniques
to divert calls to an alternative line at
home, and utilizing online communication
systems would facilitate such changes in
work practices. The author’s own healthcare
facility is subscribed to a cloud-based
patient software system allowing encrypted
remote access, therefore allowing clerical
staff to reconfigure their work practices and
operate from home.
Managing patients remotely
With the recent advancement of
telemedicine, innovative techniques could
be deployed for information gathering
and providing healthcare advice remotely.
Conversations can be had by phone, text,
Figure 2. (a, b) Our administration offices where patients are contacted for appointments are not at
the reception area.
a b
Figure 3. An example of a telemedicine platform,
useful for remote consultations.

GeneralPractice
for them leaving home may be of particular
benefit during the pandemic. With working
community members being widely
encouraged to work from home, there are a
number of aspects of healthcare provision
where this may be possible. Particular
attention should be applied to making sure
that changing innovative practices do not
compromise the use of patient-sensitive
confidential information. Encrypted
information transfer mechanisms must be
deployed and all regulatory procedures
and legislation must be strictly adhered to.
The patient must be carefully consented for
such an adjustment in management, and
informed in detail on how such a variation
would differ from the traditional face-to-
face patient contact.
Where patient contact is not
entirely necessary, such as with the delivery
of a removable appliance for example, a
clinician may consider delivering it by post
with instructions on use and perhaps a
follow-up phone call, rather than asking
a patient to attend for a formal fitting.
Patient hand hygiene,
sanitizers and habit
encouragement
Hand sanitizers, preferably delivered
through a sensor-detected, non-
touch system, should be made readily
available for patients, for example at the
reception desk at which they present
and throughout the waiting room and
facilities. A gentle encouragement to
think carefully about touching surfaces
as well as the continued touching of
faces may help create habits that would
combat the spread of disease (Figure 4).
Purchase of oral health
products
In order to act in the patients’best
interests ahead of financial reward,
patients should be discouraged
from attending the dental practice
if purchasing products, such as
toothbrushes and toothpastes, is
the only reason for their visit. They
should be advised either to purchase
such products from the most locally
convenient store or ideally purchase
them online for delivery.
Clinical and social history-
taking
A thorough history-taking process must
be performed at every dental visit in
order to gather information relevant
to the proposed dental management.
However, given the current situation, a
more in-depth scrutiny of presenting
cardio-respiratory compromise
or immuno-compromise may be
appropriate. A careful social history,
including information gathering on
domestic arrangements and recent
changes in work and living practices,
should be taken. Changes in personal
arrangements within communities may
impact on the logistics of providing
clinical care. Although close contact
during clinical examination and
procedure performing is inevitable,
dentists and assistants may carefully
consider their distances when
Figure 4. (a, b) Sanitizers for patients.
a
b
emails, videoconference calling or with
the use of one of a number of platforms
designed for remote healthcare (Figure 3).
Any adjustment of healthcare provision that
reduces patient contact or negates the need
Figure 5. If possible, the author suggests a new
culture of distancing when talking to patients.
Figure 6. Aerosol spray generated from dental
ultrasonic scaler (Copyright: Sandor Kacso/Adobe
Stock).

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inflammatory drugs, some reporting that
they could worsen the manifestation of
COVID-19 symptoms.14
Caution must be
applied when evaluating the evidence
and clinical practice should be adjusted
accordingly.
A flowchart may be used as a
guide on how to manage dental patients
(Figure 7).
Personal Protective Equipment
(PPE)
Dental professionals are well versed in the
use of PPE and the current situation has
brought such measures to the forefront of
our minds. Careful systematic hand-washing
techniques, lasting at least 20 seconds, must
be thoroughly performed whilst wearing
bare-below-the-elbow clinical attire, if
culturally and religiously acceptable. The
use of a combination of single-use gloves
and mask is of particular importance,
together with protective goggles and
visors if they do not impede magnifying
equipment. There are reports of a shortage
of masks in the market, so appointment
times may need to be adjusted in order to
maximize the use of one mask per patient.
Given the seriousness of the
pandemic situation, it is now time to
consider more enhanced measures of PPE
in dentistry, for example disposable surgical
gowns and hats as well as even more
advanced forms of PPE such as the use of
FFP2 or FFP3 respirators (Figures 8 and 9).
Writing on a recent blog using
his twitter handle15
@johndotz describes,
for the purpose of clarity, that a mask is a
loose-fitting cloth that is placed over the
nose and mouth of the wearer. Contrary
to popular belief, he describes that it is
not designed to protect the wearer, rather
to protect the patient from any coughs
and sneezes arising from the wearer,
although an element of barrier protection
from splatter of saliva and blood is useful.
Such fluids could still access the face of
the wearer as the mask is loose-fitting.
Respirators, however, are tight-fitting
masks, designed to protect the wearer from
any splatter arising from the patient. The
most commonly discussed respirator is the
N95 American standard, whereas Europe
defines the ‘filtering face piece’(FFP) in
three standards. Examples of respirators,
which also come in a valved or non-valved
Figure 7. A flowchart may be used as a guide on how to manage dental patients.
history-taking and it may perhaps be
time to start considering a new culture
of sitting or standing at a distance when
communicating with patients
(Figure 5).
Adjustment to routine decision-
making and techniques
Studies have shown that a substantial
degree of circulating and potentially
contaminated aerosol-generated water
droplets arise from the use of the high-
speed turbine, surgical handpieces,
piezotomes and ultrasonic scalers.4-11
(Figure
6). For procedures where rubber dam
isolation is possible, this should be strongly
encouraged in an attempt to eliminate
an inevitable spread of virus-containing
saliva and blood.12
Thorough drying of the
isolated tooth surfaces will further help
combat fluid spread, although tooth surface
and dental material exposure will remain.
Where clinically appropriate, the use of
aerosol-generating equipment may be
replaced with other techniques, such
as enhancing the use of excavators and
hand scalers. Clinical decision-making
may be adjusted with a thorough
informed patient consent process when
considering deferring procedures,
such as the surgical removal of teeth
and roots, or the placement of dental
implants.
There is some evidence to
suggest that oxidizing mouthwashes
have been effective in reducing salivary
viral load, so it may be prudent to ask
patients to perform a prophylactic rinse
prior to any operative intervention,
as long as there is no known contra-
indication for use. Chlorhexidine
mouthrinses have been shown to be
ineffective in attacking the SARS-CoV-2
virus.13
At the time of writing, there
has been diametrically conflicting
advice due to the lack of high quality
data on the use of non-steroidal anti-

GeneralPractice
disposed of in a yellow clinical waste
bag with ligation ties, that is placed
within a readily accessible bin that is
opened with a foot pedal. Donning
and doffing of PPE is critical for its
successful use, as it is all too easy
to make mistakes, such as touching
one’s face with sterile gloves. Targeted
training in donning and doffing
techniques, particularly for team
members who have limited or no
experience in advanced surgical
procedures and environments, is
essential.
Sterilization and surface
decontamination
The author does not consider any
measures in addition to the routine
decontamination measures necessary,
Figure 8. Enhanced protective clinical attire.
Figure 9. Full PPE for staff including surgical hat
and gown with a FFP3 mask. Figure 10. Comparison of mask types.
type, are shown in Figure 10 and the
filter capacity of the different masks are
presented in Table 2.
How the masks function is
beyond the scope of this article and there
is as yet no research evaluating their
effectiveness in protecting against the
SARS-CoV-2 virus. It is known, however,
that, as the virus diameter is 0.06−0.14
microns,16
it moves with Brownian motion,
meaning it moves in a zig-zag fashion
and therefore gets stuck in the fibres of
the mask. In essence, surgical masks are
better than no mask at all, but not quite as
good as respirators, simply because they
are loose-fitting so allow virus particles to
pass around the edges. It is easier to breath
through a mask with a valve.
The full hood, as shown worn by
an Anaesthetist in Figure 11 is considered
unnecessary for use in the dental setting.
All used PPE must be safely
STANDARD Filter capacity
FFP1 80%
FFP2 94%
N95 95%
FFP3 99%
N100 99.97%
Table 2. Filtering face pieces protection levels. FFP2, N95 and FFP3 masks are recommended for the
management of COVID-19 patients.
although when frequent stringent
practices are performed routinely in
front of a community with enhanced
awareness in the current climate, the
patients may well be further reassured
of the safe environment in which they
are being cared for. When disinfection
measures are regularly visibly deployed
in the non-clinical areas, such as surfaces
of the reception desks, chairs and door
handles, the patient experience is likely to
be enhanced further.
Waiting room arrangements
The waiting room should be arranged
to minimize patients’and accompaniers’
exposure to each other in line with
the government’s ‘social distancing’
policy. Where possible, chairs should be
positioned at a safe distance and not
facing each other (Figure 12). The room
should be adequately ventilated and
products that may harbour the virus,
such as magazines, coffee cups and toys
removed from the area. Posters may be
placed on the walls displaying public
health announcements and advice
for patients such as what to do when
sneezing (Figure 13).
Information collection
mechanisms, such as medical history or
registration forms, should be adjusted to
minimize contact when utilizing shared
use of pens or clinipads, by carrying out
stringent surface disinfection techniques.
Patients should be encouraged not to
bring accompanying friends and family
to appointments unless particularly
necessary. Appointment times should be

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GeneralPractice
Figure 11. A powered air purifying respirator
hood.
adjusted in order to minimize the chances
of over-running, therefore reducing the
number of patients in the waiting room.
Domiciliary visits
Vulnerable, ‘at risk’patients or individuals
who may find difficulty in attending the
dental premises due to reductions in
public transport availability may benefit
from domiciliary home visits or access to
local mobile units (Figure 14). For dentists
wishing to seize on the opportunity of
this changing face of healthcare and
diversifying into an alternative approach
to dental service delivery, foldable dental
chairs (Figure 15) and portable dental
equipment (Figure 16) are available on
the market. Careful consideration must be
given to the required approval of the Care
Quality Commission (CQC), regulatory
bodies and indemnity providers.
Chaperoning, assistance and personal
safety also becomes pertinent for careful
consideration.
Make every contact count
Whilst tasked to cater for a patient’s
specific dental needs, according to our
training, competence and indemnity
cover, contact with a patient may provide
a valuable opportunity to investigate
their medical and social wellbeing
and provide generic care, support and
advice to an appropriate level. Any
arising concerns could be escalated to
our medical colleagues through the
recognized access pathways.
Given the global pandemic
situation and the drastically increasing
number of the population becoming
unwell, the clinical environment may
provide an opportunity to perform
a basic generic medical examination
that could include the measurement
of systemic body temperature,
preferably with a non-contact
forehead thermometer (Figure 17) and
measurements of vital signs that include
blood pressure, pulse, and oxygen
saturation. Any concerns must then
be relayed to our medical colleagues
through the recognized referral and
management pathways.
Main stream media, Social
Media and community
communication
There is one leading topic of discussion
and interest in all media outlets and that is
COVID-19. The author strongly encourages
all dental healthcare professionals to
remain closely engaged with all discussions
in order to be kept continually updated
on a rapidly-developing global situation.
Figure 18 shows an example of how
dental professionals have taken the
lead to communicate with each other.
Inevitably, however, there is a vast amount
of circulating misleading information, so
caution must be applied when receiving
information. Furthermore, we must be
mindful that we are representatives of the
healthcare system within our communities,
commanding particular respect when
disseminating information relevant to
Figure 12. (a, b) In the waiting room, in line with the government’s ‘social distancing’policy, where
possible, chairs should be positioned at a safe distance and not facing each other.
a
b

GeneralPractice
disease. Extreme caution must therefore be
applied when communicating information
and opinions. If we are not sure about what
we are about to post and haven’t verified it,
it would be prudent not to post it.
Wider community contributions
The healthcare provider is often considered
the trustworthy upstanding member of the
community. This professional reputation
may become particularly valuable during
this unprecedented time of community
need. There has been no more pertinent
peace-time occasion when checking on
friends and neighbours, particularly the
vulnerable, became of such valuable
importance. If situations arise whereby
clinical dental services somewhat reduce
or diminish, our expertise may be of
substantial use within the community, or
even in primary or secondary healthcare
facilities as an adjunctive member of the
clinical team.
Financial, business and
personal considerations
There are many relevant fiscal factors that
will require careful consideration and
implementation. Many dental practices are
inevitably seeing a diminishing number
of attending dental patients and this is
undoubtedly affecting income, as well
as the achievement of units of dental or
orthodontic activity. Changes in patterns
of service provision may well lead to
difficult situations that include premises
and equipment costs, as well as changes in
staffing structure. Difficult decisions may
need to be taken. Business proprietors
should listen to announcements on the
possibility of government support with
business rates, mortgages and rental
payments. There may be times when the
healthcare professional needs support
during these difficult times. Any member
of staff showing signs of prolonged
heightened anxiety during this episode
must be supported appropriately, utilizing
professional services, if required.
A recognized phenomenon
during times of a national crisis is an
increase in crimes, as efforts and funding in
public services are re-directed. One incident
was recently reported to the author when a
member of the public entered a healthcare
facility and stole a bottle of hand sanitizer
and a box of masks, then escaped. Extra
vigilance is required during these uncertain
times.
Personal health
According to the advice provided at the
time of writing, any member of the dental
team showing signs or symptoms suspicious
of COVID-19, or living in a household where
another individual has tested positive,
should immediately remove themselves
from the workplace, self isolate and perform
a test for the virus. Any positive result must
then be relayed back to the workplace and
to any patients seen during the previous
seven-day period. Any members of the team
considered vulnerable, such as those with
underlying medical conditions or pregnant
women, may consider government advice
and stay at home. Data from Italy has shown
that up to 10% of cases diagnosed with
COVID-19 are healthcare workers.17
Staff
shortages during this crisis are inevitable
but care must be taken not to allow this
to compromise patient and staff safety.
Working without assistance or chaperoning,
or without required supervision, is strongly
discouraged.
There is no better time than
the present to concentrate on one’s own
Figure 13. (a–d) Examples of patient information
posters.
a
b
c
d

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Figure 14. Mobile dental van.
Figure 15. Foldable dental chair.
Figure 16. Portable dental unit.
Figure 17. Infrared forehead thermometer.
immune system. Advice relevant to
general wellbeing, such as getting
good quality sleep, eating healthily and
engaging in regular exercise in order to
boost immune function applies as much
now as ever.
Governance
The situation is fluid and continually
changing as incidents occur, advice
updated, and information produced
through the media or otherwise. A daily
morning meeting led by the Governance
Lead is particularly worthwhile, where
team members can share information and
discuss updates to standard operational
procedures. This allocated time should be
utilized to develop continually and learn
from incidents and reports.
The Central Alerting System
(CAS) is a useful tool for urgent patient
safety communications. Primary care
providers should be encouraged to register
with the Medicines and Healthcare products
Regulatory Agency to receive CAS alerts at
https://www.cas.mhra.gov.uk/Register.
aspx.
The CQC has announced the
postponement of routine inspections but
particular attention should be applied in
order to ensure stringent compliance to
governance protocols.
In order to maintain safe
social distancing, healthcare professionals
may consider subscribing to online
distance learning continuing professional
development programmes rather than
attending courses and lectures with large
numbers of delegates. In light of the
current need, educational courses relevant
to COVID-19 would be advised, such
as those that include enhanced cross-
infection control.
Conclusion
With the continually changing picture
and government advice regarding
COVID-19, and the sparse advice from
formal dental organizations, this article
attempts to provide a structured
method of considering aspects of dental
care pertaining to service provision.
It describes methods of providing
dental care to be considered during
this unprecedented period of altered
community management. Many may be
wholly inappropriate when given careful
consideration at an individual level, but
worthy of thinking about all the same.
Official government guidance
must also be continually followed.18
In
much the same way as all professional
practice, care must be taken not to stray
from official guidance, unless justifiable.
A temporary adjustment to

GeneralPractice
Figure 18. One of a number of social networking pages demonstrating how dentists have taken the lead in sharing information as they develop themselves
during these challenging times for the profession.
traditional practices should be considered
during these challenging times as we strive
to reduce the spread of this world-changing
disease. The face of healthcare will inevitably
change in response to the current crisis.
Our profession must adapt to change our
practices appropriately.
Conflict of interest statement
The author has no conflict of interest in
submitting this article for publication.
Open access and expediting
publication
Given the unprecedented seriousness of the
current global situation and the extremely
rapidly changing picture, the author requests
that review and editing of the article is
expedited for swift publication and open
access is granted in the interests of safety for
patients, professionals and communities at
large.
References
1. Cook T, El-Boghdadly K. The UK COVID-19 epidemic:
time to plan and time to act. The Anaesthesia
Blog. Peri-operative medicine, critical care and
pain. 6th March 2020. https://theanaesthesia.
blog/2020/03/09/the-uk-covid-19-epidemic-time-
to-plan-and-time-to-act/
2. Wang Z, Yang B, Li Q, Wen L, Zhang R. Clinical
features of 69 cases with Coronavirus Disease 2019
in Wuhan, China. Clin Infect Dis 2020 Mar 16. pii:
ciaa272. doi: 10.1093/cid/ciaa272.
3. https://www.dentistrytoday.com/news/
todays-dental-news/item/6135-ada-says-non-
emergency-treatment-should-be-postponed
4. Walls HJ, Ensor DS, Harvey LA, Kim JH, Chartier
TR, Hering SV et al. Generation and sampling of
nanoscale infectious viral aerosols. Aerosol Sci Tech
2016; 50: 802−811.
5. Cleveland JL, Gray SK, Harte JA et al. Transmission
of blood-borne pathogens in US dental health
care settings: 2016 update. J Am Dent Assoc 2016;
147: 729−738.
6. Harrel SK, Molinari J. Aerosols and splatter in
dentistry: a brief review of the literature and
infection control implications. J Am Dent Assoc
2004; 135: 429−437.
7. Wei J, Li Y. Airborne spread of infectious agents in
the indoor environment. Am J Infect Control 2016;
44: S102−S108.
8. Otter JA, Donskey C, Yezli S et al. Transmission
of SARS and MERS coronaviruses and influenza
virus in healthcare settings: the possible role of
dry surface contamination. J Hosp Infect 2016; 92:
235−250.
9. Van Doremelan et al. Aerosol and surface stability
of SARS-CoV-2 as compared with SARS-CoV-1.
N Engl J Med March 17 2020. doi: 10.1056/
NEJMc2004973.
10. Su J. Aerosol transmission risk and
comprehensive prevention and control strategy
in dental treatment. Zhonghua Kou Qiang
Yi Xue Za Zhi 2020; 55: E006. doi: 10.3760/
cma.j.cn112144-20200303-00112. (In Chinese).
11. Droplets and aerosols in dental clinics and
prevention and control measures of infection.
Zhonghua Kou Qiang Yi Xue Za Zhi 2020; 55: E004.
doi: 10.3760/cma.j.cn112144-20200221-00081. (In
Chinese).
12. Samaranayake LP, Reid J, Evans D. The efficacy of
rubber dam isolation in reducing atmospheric
bacterial contamination. ASDC J Dent Child 1989; 56:
442−444.
13. Peng X, Xu X, Li Y et al. Transmission routes of 2019-
nCoV and controls in dental practice. Int J Oral Sci
2020; 12(9). https://doi.org/10.1038/s41368-020-
0075-9
14. Day M. Covid-19: ibuprofen should not be used for
managing symptoms, say doctors and scientists. BMJ
2020; 368: m1086. https://doi.org/10.1136/bmj.
m1086 (Published 17 March 2020).
15. https://fastlifehacks.com/n95-vs-ffp/
16. Zhu et al. A novel Coronavirus from patients with
pneumonia in China. N Engl J Med 2020; 382:
727−733 doi: 10.1056/NEJMoa2001017 February
20 2020.
17. https://www.epicentro.iss.it/coronavirus/sars-cov-
2-sorveglianza-dati
18. https://www.england.nhs.uk/wp-content/
uploads/2020/02/20200305-COVID-19-PRIMARY-
CARE-SOP-DENTAL-PUBLICATION-V1.1.pdf

DentalPsychology
Body Dysmorphic Disorder:
a Guide to Identification and
Management for the General
Dental Practitioner
Enhanced CPD DO C
Abstract: Body Dysmorphic Disorder (BDD) is a relatively common psychiatric condition in which the individual is disproportionately
concerned about an aspect of his/her appearance. People with BDD are highly likely to seek cosmetic dental treatment. However, the
provision of such treatment is contra-indicated. This article will identify simple techniques for practitioners to screen for and manage
patients with BDD.
CPD/Clinical Relevance: This article addresses the management of patients with a specific psychiatric illness who are likely to present for
cosmetic dental treatments.
Dent Update 2020; 47: 303–313
Adina Rosten
Tim Newton
Adina Rosten, Year 5 BDS Student
(email: adina.rosten@kcl.ac.uk) and Tim
Newton, BA, PhD, King’s College London
Dental Institute, Floor 26, Tower Wing,
Guy’s Hospital, London SE1 9RT, UK.
Throughout the course of our lives, almost
all of us have felt dissatisfied with our
appearance and tried to improve it. After all,
we are hounded by images and messages
from all sides telling us that we are not
pretty enough or we are not skinny enough.
Who wouldn’t like a flatter stomach, a more
chiselled body, blemish-free skin? If we
had the chance to use a magic wand to
look better, most of us would. In fact, most
of us try on a daily basis. From spending
hours in changing rooms ensuring that
clothes are as flattering as they can be,
going on fad diets, (which just make us
miserable) and spending fortunes on the
latest moisturising cream promising to
knock years off us, we have all tried to
alter our image to some degree. However,
for some people, these concerns are not
just about disliking a body part; they’re
preoccupied with it. Every waking thought
revolves around their perceived flaw and
imperfection and their worries about their
looks lead to distress and emotional pain,
resulting in an interference in their quality
of life. They no longer want to go to work
for fear that people will notice the slight
facial blemishes. They are terrified to go
to their high school prom due to concerns
that their thinning hair will be noticed. They
can’t engage in meaningful relationships
due to the daily inner voice telling them
that their breasts are ‘tiny’. In reality, these
supposed flaws are usually not noticeable
to those around them, or considered
minimal. However, for the sufferer, the
problem looks repulsive and abhorrent,
magnified by the mind’s eye.
Such people are considered
to suffer from a mental illness known as
Body Dysmorphic Disorder (BDD), which is
classified under the Chapter of ‘Obsessive
Compulsive and Related Disorders’in the
Diagnostic and Statistical Manual of Mental
Disorders 5th
Edition (DSM-5®).1
The criteria used for diagnosis
are outlined in Table 1. In previous DSM
editions, BDD was classified both as a
somatoform disorder and a delusional
variant was also classified as a psychotic
disorder. However, there was evidence
to suggest that these two variants had
more similarities than differences and that
they were likely to be the same disorder,
characterized by a spectrum of insight.2
As
such, DSM V extended the original criteria
and added a specifier, indicating the degree

DentalPsychology
number of epidemiological studies have
been conducted throughout the years and
prevalence rates of between 0.7%-2.4%
have been reported amongst different
populations.3–5
It is, however, important to
note that prevalence varies, depending on
the setting that patients are in. Interestingly,
it has been shown that the prevalence rates
of BDD in those having cosmetic dental
surgery or orthodontic treatment range
from 4.2-7.5%,6
implying that dentists are
more likely to encounter sufferers of BDD
than the general population.
Clinical features
Amongst sufferers, the body part causing
the most distress varies from person
to person. However, there are certain
areas that are more frequently cited as
troublesome than others. These include
nose, eyes, ears, balding, genitals and
breasts, and it is not uncommon for a
patient to have an issue with more than
one of these body parts at any one time.7
Table 2 lists examples of real life concerns
from patients suffering with BDD, together
with their associated behaviours and
consequences.
Veale et al found that 86% of
patients perceived themselves to have a
facial defect, with 12% reporting specific
teeth defects,8
whilst Phillips discovered
that 20% of sufferers had concerns with
their teeth.7
As such, it is highly likely that
dentists, orthodontists, plastic surgeons
and other specialists working in the facial
region will become involved with such
patients and, thus, need to be aware of
their identification and management.
Orthodontic examples might include
concerns over the size and shape of a
patient’s teeth, as well as the perceived
‘straightness’of teeth, whilst complaints
that may present to the general dentist may
include dissatisfaction with the whiteness of
a patient’s teeth.
The high levels of distress
experienced by sufferers of BDD can
sometimes lead to patients attempting to
take their own life. In a study conducted
by Phillips it was found that 79.5% of
185 subjects had experienced suicidal
ideation and 27.6% had a history of a
suicide attempt, which was found to be 45
times higher than levels experienced by
the general population.9
These extremely
1. Preoccupation with one or more perceived defects or flaws in physical appearance that
are not observable or appear slight to others.
2. At some point during the course of the disorder, the individual has performed
repetitive behaviours (eg mirror checking, excessive grooming, skin picking, reassurance
seeking) or mental acts (eg comparing his or her appearance with that of others) in
response to the appearance concerns.
3. The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
4. The appearance preoccupation is not better explained by concerns with body fat or
weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Table 1. Diagnostic criteria for body dysmorphic disorder.
Appearance Concerns Associated Behaviours and Consequences
Nose misshapen Believes others take special notice
Avoids mirrors
Had nose surgery
Thinning hair Excessive hair combing
Checks mirrors excessively
Social avoidance
Avoids haircuts
Gets a hair weave
Spectacles Wears tinted glasses to hide eyes
Hair too curly Frequent hair perms and straightening
Compares self with others
Penis too small Stuffs shorts and wears shirt down to knees to cover crotch
Breasts too small Wears padded bras
Unable to go to school, work, swim or socialize
Ugly face Checks mirrors, car bumpers and windows excessively
Difficulty interviewing for jobs
Fat waist Checks mirrors and store and car windows
Changes clothes frequently
Sits and stands only in certain positions so waist isn’t visible
under clothing
Table 2. Examples of preoccupations, behaviours and consequences.28
of insight regarding BDD beliefs. As a
result, the delusional variant of BDD is no
longer considered a delusional disorder
but rather as a specific form, in which a
patient with absent insight/delusional
beliefs is‘completely convinced that the body
dysmorphic disorder beliefs are true’.1
These
patients may be challenging to treat, so it is
useful to ascertain whether this specifier is
relevant at an early stage.
Patients presenting to the
dental clinician may well suffer from BDD,
with varying levels of insight, and dentists
may be the first to spot them. In this
review, how to identify when a patient’s
aesthetic concern is considered ‘normal’
and when alarm bells should be ringing
will be the focus. The best way to manage
such patients and advise on the process of
referral will also be addressed.
Body dysmorphic disorder: an
overview
Prevalence
Body dysmorphic disorder appears to
be a relatively common mental health
condition, although exact prevalence is
difficult to ascertain due to the shame
commonly associated with the illness. A

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Name of Screening Tool Number of Items Comments
Body Dysmorphic Disorder Questionnaire6
(Figure 1)
4 items  Easy and brief, so suitable in dental practice
 High value of sensitivity (94%–100%)
 High value of specificity (89–93%)15,16
Yale-Brown Obsessive Compulsive Scale
Modified for body dysmorphic disorder17
12 items  It rates the severity of BDD symptoms by asking patients to base
their answers on the last week
 First five items relate to thoughts, the second five relate to
behaviours and final two assess insight and avoidance
 Most BDD treatment studies use this scale as it is considered gold
standard18
 Less useful in dental practice as it requires specialist training and is
lengthy to administer
Cosmetic Procedure Screening Scale19
9 items  Originally developed to help identify sufferers of BDD who might
express dissatisfaction with a cosmetic procedure, but underlying
basis may be useful as a screening tool before dental cosmetic
procedures
 This scale has convergent validity, test-retest reliability and
acceptable internal consistency
 This scale also has a high sensitivity for the diagnosis of BDD in
those who are likely to seek a cosmetic procedure19
 Although an excellent measure, likely to be unwieldy for use in
dental setting
Dysmorphic Concern Questionnaire20, 21,22
(Figure 2)
7 items  This questionnaire doesn’t aim to establish a diagnosis of BDD but,
rather, to assess Dysmorphic concern as a symptom
 Although not developed to screen clinically for BDD, it has uses in
non-psychiatric clinical settings, such as the dentist, as a brief self-
report screening tool
Marks and Matthew Suicidal Ideation Scale23
3 items  This is a useful screening tool given that BDD is associated with high
levels of suicidal ideation
 It is a quick and easy assessment tool so easy to use in the dental
practice
 Arguably should be used whenever assessing patient for BDD using
any of the other tools
Table 3. Screening tools for BDD.
high rates indicate the necessity for dental
professionals to spot sufferers and to refer
them for psychiatric help immediately
rather than carrying out dental treatment.
Assessment of patients
If a clinician suspects that a patient may be
suffering from BDD, it is important that a
basic assessment is carried out to check if
he/she is suitable for dental treatment or
whether he/she would be better placed to
receive psychological support. In numerous
research papers, both dental-related and
otherwise, it has been found that those
suffering from BDD are rarely satisfied with
the treatment they initially sought help
for, as the issue is a mental one rather than
a physical one.10
This can have far-reaching
effects for dentists treating them, making
early detection and appropriate management
of paramount importance.11
Below is a useful
guide on how best to assess patients.
Tip 1: Create a safe environment
Before raising any concerns dentists may
have, it is crucial that they follow this step
in order to maximize a patient’s feeling of
security in the dentist and to allow an open
and honest dialogue. Dentists should make
it clear that any information disclosed will
remain confidential unless they feel they are
at risk of harming themselves or others. It
is also important that the dentist limits the
number of people in the room to make the
patient feel less intimated.
Tip 2: Schedule a longer appointment time
It is advisable to schedule a longer
appointment time than usual as this will
allow ample time for discussion, which will
reduce the risk of the patient feeling rushed
and pressurized.12
This will maximize the
likelihood of making the correct diagnosis
and signposting the patient to accessing
the correct professional help.
If a new patient presents to
the surgery with tell-tale signs of BDD,
but there isn’t sufficient time to have an in
depth discussion with him/her, it is prudent
to schedule in another appointment with

DentalPsychology
underlying mental health issues he/she
may have.
Tip 4: Ask yourself whether the distress
reported by the patient is proportionate
given the extent of the disfigurement
present.
It is important to realize that BDD
patients attending a dental clinic are
likely to want some form of cosmetic
dental treatment, such as braces or tooth
whitening. As a result, patients might
exaggerate or deviate from the truth in
an attempt to encourage the dentist to
agree to offer treatment.14
This could
skew the assessment results, leading to
misdiagnosis. Therefore, it is important
that the clinician does not necessarily
take the discussion at face value.
However, it is also important to realize
that patients often have beliefs about
their appearance that they may truly
feel and, as such, the clinician has to be
careful to deny these statements and try
to validate the extent of the distress from
the stated disfigurement.
Tip 5: Use a screening tool
There are many screening tools available
to help establish whether a patient
might suffer from BDD. Some are
lengthier than others and may not be
appropriate for use in a dental surgery. It
is recommended that dentists familiarize
themselves with all the screening
tools available and then decide which
one they feel most comfortable with
and which they think will be most
amenable to their day-to-day practice.
It is important to note that these are
just screening tools and not diagnostic
tools. Dentists are not qualified to make
a formal diagnosis of BDD using these
tools but they can help determine
whether a referral should be made.
A screening tool also means that the
decision is based on a relatively objective
measure in addition to clinical opinion.
Ideally, a formal diagnosis will be made
following a face-to-face interview with a
trained clinician. Examples of commonly
used screening tools with information
on their scoring system and uses can be
found in Table 3, with samples of some of
the questionnaires included displayed in
Figures 1-3.
Table 4 provides two
Figure 1. Body Dysmorphic Disorder Questionnaire.
a larger time allocation. Any treatment
which the patient requests should be
delayed until this discussion has been
carried out rather than carrying out
rushed, and potentially damaging,
treatment during that first appointment.
Tip 3: Take a thorough medical history
Although many patients suffering from
BDD will present to the practice unaware
of their condition, some will have already
been diagnosed but may be reluctant to
divulge this information, especially if not
directly questioned about it. Therefore, it
is good practice to get into the habit of
asking all patients if they have ever been
diagnosed with a mental health condition.
It is likely that many patients may still
not share this information but, by asking
the question, there is an increased
probability that more will share than
if the question wasn’t asked. Another
useful clue may be to ask patients if
they are taking any medications. Many
people diagnosed with BDD may
be taking antidepressants, with the
medication of choice being selective
serotonin re-uptake inhibitors,13
and
medication treatment is often essential
for more severely ill and suicidal
patients. Therefore, a declaration of
regular medication may help a clinician
build up a more comprehensive image
of a patient’s background and any

DentalPsychology
examples of possible cases of BDD,
identifying the key features as they may
present in dental practice.
Is it safe to carry out the
treatment?
The short answer is no. Instead, the patient
should be referred for specialist psychological
support. Once this has been undertaken, it
will become clear what dental treatment, if
any, is appropriate. The reasons for this are
discussed in more detail below.
Treatment is bad for the patient
A patient presenting to a dentist in obvious
distress about a perceived defect and a
convincing argument as to why he/she needs
treatment can be difficult to refuse. However,
numerous studies have been conducted
over the years which have demonstrated
that surrendering to the patient’s requests
have not benefited the patient at all.
One such study, conducted by Phillips et
al, found that more than two-thirds of
patients who received physical treatment
with no accompanying psychiatric support
experienced no alleviation or worsening
in their BDD symptoms, usually because
the patient’s concerns had simply been
transferred to another body part or he/she
was worried that the improvement would
get worse again.24
In this particular study,
only 7.3% of all treatments resulted in both
a decrease in concern with the treated
body part as well as an alleviation in BDD
symptoms. Similar findings were reported
Figure 2. Dysmorphic Concern Questionnaire.
Figure 3. Marks and Matthew Suicidal Ideation Scale.
by Crerand et al, in which 91% of patients
experienced no change in overall BDD
symptoms after treatment25
and Veale et al,
in which 81% of patients who had sought a
consultation or operation were dissatisfied
or very dissatisfied.8
These findings are clear
indications that provision of the requested
treatment is clearly not in the patient’s best
interest when he/she is suffering from BDD.
Treatment is bad for the dentist
Unfortunately, not only can treating
BDD patients be detrimental to the
patient themselves, but it can also prove
detrimental to the treating clinician as a
result of the patient’s unattainably high
standard, of which the dentist will almost
always fall short. As a consequence of the
perceived failure to improve a patient’s
image, it is not uncommon for him/her to
attempt litigation against his/her clinician.
In 2001, all members of the American
Society for Aesthetic Plastic Surgery (ASAPS)
were emailed the ‘2001 Body Image Survey’,
of which 265 members responded. The
survey revealed that 40% of respondents
had been threatened by a patient suffering
from BDD; 29% had been threatened
legally, 2% physically and 10% both legally
and physically.26
It is important to be aware
that legal action may be taken against a
clinician, even when consent has been
taken, as demonstrated in the Lynn vs
Hugo case of 2001.27
Although the patient
didn’t succeed in her claim, it raised the
interesting, and potentially concerning
point that patients suffering from BDD
may well be declared unfit to consent due
to their impaired mental ability. This may
well result in a clinician being found liable
in a court of law, emphasizing how critical
it is not to proceed with treatment when
BDD is suspected, but rather to signpost a
patient towards psychiatric or psychological
services for further treatment.
Concerns about talking to patients about BDD
It is natural that a dentist will feel
uncomfortable talking with a patient about
what is potentially a serious psychiatric
diagnosis. However, it is important to bear
in mind the following:
1. The dentist is acting in the best interests
of the patient: Although the patient may
feel that the dentist is being vindictive
and certainly doesn’t appreciate that this

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Miss A, aged 30 years, presented at an orthodontic clinic
requesting treatment for her 'crooked' upper anterior teeth.
She also felt her teeth were too yellow and was keen to discuss
tooth whitening. She was generally anxious in the dental surgery.
She had a Class I occlusion with moderate crowding and an
average overbite. A number of teeth showed signs of erosion. The
orthodontist advised her that fixed braces would be required for a
period of 2 years to correct her crowding and bite with extractions
required to alleviate the crowding. Miss A described how she could
not abide a gap during any of the treatment and asked again
about tooth whitening.
Miss A was currently working and had an active social
life. She had joined a dating website and regularly went on dates.
She was very unhappy with the appearance her teeth and keen to
correct the crowding and improve her appearance. She had looked
on the internet about the possibility of having braces.
Mr B, aged 28, was referred to the orthodontic department by his
dentist for an assessment of his Class II division 2 malocclusion
with increased overbite. He had recently registered with the GDP
and at his first appointment discussed the issues concerning him,
prompting the referral. On examination Mr B had a significant
skeletal II background with increased overbite, complete to the
palate and retroclined upper labial segment. His teeth were in
good condition and his oral hygiene excellent. Further discussion
during the examination revealed that Mr B was also concerned
about the appearance of his chin and deep groove under his
bottom lip.
Mr B was married and unemployed. He placed much
emphasis on the importance of an anterior bite and stressed how
he felt his facial appearance gave him a lack of self confidence,
and may be related to his difficulty in finding employment. He had
looked on the internet for information on osteotomies.
Additional Medical History
Miss A was on no current medication and had been hospitalized as
a child for tonsillectomy. She had previously been diagnosed with an
eating disorder, for which she had received psychiatric treatment. She
attended a GDP in the area for some time and had little more than
check-ups in that time. She had not had any treatment for her erosion
but was aware that it was linked to her previous eating disorder.
Mr B was allergic to Penicillin and was taking fluoxetine. He had
undergone surgery twice in the previous four years, having been
administered a General Anaesthetic on both occasions.
He registered with this dentist recently although had been living in the
area some time, and on closer questioning revealed that he had seen a
number of dentists in the area, including another orthodontist, about
the possibility of an osteotomy.
Overall Assessment
Miss A clearly has a history of psychiatric illness, which is often a
co-morbidity in BDD, though note that a diagnosis of an eating
disorder would normally exclude a co-existing diagnosis of body
dysmorphophic disorder.
This case suggests a failure of communication and
a difference in priorities between the dentist and the patient.
For a single woman in her 30s, appearance is a key issue and
it is understandable that the patient is concerned about the
appearance of her teeth. There is little evidence that her concerns
are disproportionate and her questioning about the process of
orthodontics highlights her lack of information to date rather than
unrealistic expectations per se.
Further information about her psychological state
(including depression and suicidal ideation) would be important
to ascertain as well as information on any impact of the perceived
defect on her daily life (though note she has a good social life and
is working).
Mr B, though attending for a seemingly appropriate treatment,
shows many features of body dysmorphic disorder. His concerns
that the appearance of his teeth and chin is preventing him
getting a job are disproportionate to the actual problem. Accessing
information on the internet is an accepted background in many
instances, but may be an indication of preoccupation with a
condition or treatment. Discovering that he has seen someone else
about the possibility of an osteotomy is also an indication of his
preoccupation with appearance.
He has had surgery twice in the previous four years. It
would be important to ascertain what this was for and whether it
could conceivably be connected to body dysmorphic disorder. He
is taking an anti-depressant medication suggesting low mood, a
symptom of body dysmorphic disorder. It would be important to
gain further information about his psychological state, including
any suicidal ideation.
Table 4. Examples of possible cases of body dysmorphic disorder.
is in their best interest, in the long run,
he/she will hopefully come to realize
this. Even if not, a dentist should be
reassured that he/she is doing the right
thing and shouldn’t be disheartened
if he/she experiences animosity and
aggression from the patient.
2. It is likely that the patient is
experiencing distress: Try to focus on the
fact that the patient could benefit from
help. A phrase that is often helpful is,
‘The solution to your stress is not further
dental treatment at this time’. Perhaps
combined with focusing on the future,
‘Once you feel in a better place in terms of
your worries and anxieties, that is a much
better position for us to think about what
dental treatment you need’.
3. The dentist is not alone: When faced
with a difficult patient, it can sometimes

DentalPsychology
be overwhelming and clinicians may
feel that they have been backed into a
corner with no support. This can leave
them feeling anxious and worried about
potential repercussions they may if they
give in to the patient. Keep good notes,
and speak to a representative of your
defence organization or a colleague.
Making a referral
Guidance from the National Institute
for Health Care Excellence recommends
that, in the majority of cases, the most
appropriate care can be provided in
primary care settings, so referral to the
individual’s General Medical Practitioner
should be considered as the first step.
Alternatively, the dental team may
consider a direct referral to clinical
psychology services. Furthermore,
there are some considerations which
might suggest that it is appropriate to
seek urgent support from psychiatric
and psychological services. This is
particularly the case if the patient has
expressed suicidal thoughts. Where
such thoughts are current, emergency
referral to psychiatry via Accident and
Emergency services should be made.
When writing a referral letter,
there are certain key points a dentist
should make sure to include:
 Patient’s name;
 Patient’s date of birth;
 Patient’s address;
 Any dental problems;
 Any treatment performed;
 Concerns the dentist may have
including findings from any screening
tools;
 Recommendations for onward
referral.
It is important that the
patient is aware that the referral letter
is being made and that permission has
been granted. If a patient refuses to
allow the clinician to send the letter, the
dentist can still make a referral if he/
she feels that the situation is sufficiently
concerning to warrant such a step, for
example if there is danger to the patient
(such as suicidal ideation) or to others.
As with all treatment,
it is crucial to keep very careful
contemporaneous notes with a detailed
record of any referrals that may have
been made. This will be particularly
important if referral is made without
consent. The reasons for taking these
steps should be clearly documented.
Conclusion
Body dysmorphic disorder is a
distressing psychiatric illness where
the individual is disproportionately
concerned about his/her appearance.
People with BDD are likely to present
for cosmetic dental treatments. Dental
practitioners should be equipped with
techniques for screening individuals
for BDD, discussing their concerns
with patients and making appropriate
referrals.
Useful Resources for Clinicians
1. For further information on BDD,
including relevant reading and
online questionnaires, see the Body
Dysmorphic Disorder Foundation
http://bddfoundation.org/
2. For guidance on assessment of
people with BDD, see Cunningham
SJ, Feinman C. Psychological
assessment of patients requesting
orthognathic treatment and the
relevance of body dysmorphic
disorder. Br J Orthod 1998; 25:
293–298.
3. For information leaflets suitable for
patients, and for information for
clinicians working with individuals
with body dysmorphic disorder,
see the National Institute for
Health and Clinical Excellence
(NICE) http://www.nice.org. uk/
Guidance/CG31
4. For a patient friendly website if
wanting to offer patients a place
that will understand them, see
‘Mind’and direct them to the
BDD specific section https://
www.mind.org.uk/information-
support/types-of-mental-health-
problems/body-dysmorphic-
disorder-bdd/#.WZHLpXeGPOQ
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent
was obtained from all individual
participants included in the article.
References
1. American Psychiatric Association.
Diagnostic and Statistical Manual
of Mental Disorders (DSM-5®) 5th
edn. Washington DC: American
Psychiatric Publishing, 2013.
2. Phillips KA. Psychosis in body
dysmorphic disorder. J Pyschiatric
Res 2004; 38: 63–72.
3. Faravelli C, Salvatori S, Galassi
F, Aiazzi L, Drei C, Cabras P.
Epidemiology of somatoform
disorders: a community survey in
Florence. Soc Psychiatry Psychiatr
Epidemiol 1997; 32: 24–29.
4. Koran LM, Aboujaoude E, Large
MD, Erpe RT. The prevalence of
body dysmorphic disorder in the
United States adult population. CNS
Spectr 2008; 13: 316–322.
5. Otto MW, Wilhelm S, Cohen
LS, Harlow BL. Prevalence of
body dysmorphic disorder in a
community sample of women. Am
J Psychiatry 2001; 158: 2061–2063.
6. Veale D, Gledhill LJ, Christodoulou
P, Hodsoll J. Body dysmorphic
disorder in different settings: a
systematic review and estimated
weighted prevalence. Body Image
2016; 18: 168–186.
7. Phillips KA. Body dysmorphic
disorder: recognizing and treating
imagined ugliness. World Psychiatry
2004; 3: 12–17.
8. Veale D, Boocock A, Gourany K,
Dryden W, Shah F, Willson R et al.
Body dysmorphic disorder: a survey
of Fifty Cases. Br J Psychiatry 1996;
169: 196–201.
9. Phillips KA. Suicidality in body
dysmorphic disorder 2007; 14:
58–66.
10. Polo M. Body dysmorphic disorder:
a screening guide for orthodontists.
Am J Orthod Dentofac Orthop 2011;
139: 170–173.
11. Thompson, Catherine M, Durrani
AJ. What is the place for placebo in
the management of psychogenic
disease? J R Soc Med 2007; 100:
60–61.
12. Scott SE, Newton JT. Body
dysmorphic disorder and aesthetic
dentistry. Dent Update 2011; 38:
112–118.

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13. Phillips KA, Hollander E. Treating body dysmorphic disorder with
medication: evidence, misconceptions, and a suggested approach.
Body Image 2008; 5: 13–27.
14. Hepburn S, Cunningham S. Body dysmorphic disorder in adult
orthodontic patients. Am J Orthod Dentofacial Orthop 2006; 130:
569–574.
15. Brohede S, Wingren G, Wijma B, Wijma K. Validation of the body
dysmorphic disorder questionnaire in a community sample of
Swedish women. Psychiatry Res 2013; 210: 647–652.
16. Phillips KA, Atala KD, Pope HG. Diagnostic instruments for body
dysmorphic disorder. New research program and abstracts,
American Psychiatric Association 148th Annual Meeting: Miami,
1995: p157.
17. Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR, DeCaria
CM, Goodman WK. A Severity rating scale for body dysmorphic
disorder: development, reliability and validity of a modified
version of the Yale- Brown Obsessive Compulsive Scale.
Psycopharmacology Bull 1997; 33: 17–22.
18. Krebs G, Fernández de la Cruz L, Mataix-Cols D. Recent advances
in understanding and managing body dysmorphic disorder. Evid
Based Ment Heal 2017; 20: 71–75.
19. Veale D, Ellison N, Werner TG, Dodhia R, Serfaty MA, Clarke A.
Development of a cosmetic procedure screening questionnaire
(COPS) for Body Dysmorphic Disorder. J Plast Reconstr Aesthetic
Surg 2012; 65: 530–532.
20. Oosthuizen P, Lambert T, Castle DJ. Dysmorphic concern:
prevalence and associations with clinical variables. Aust New Zeal J
Psychiatry 1998; 32: 129–132.
21. Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic Concern
Questionnaire: a screening measure for body dysmorphic disorder.
Aust N Z J Psychiatry 2010; 44: 535–542.
22. Stangier U, Janich C, Adam-Schwebe S, Berger P, Wolter M.
Screening for body dysmorphic disorder in dermatological
outpatients. Dermatology Psychosom/Dermatologie und Psychosom
2003; 4: 66–71.
23. Marks IM, Mathews AM. Brief standard self-rating for phobic
patients. Behav Res Ther 1979; 17: 263–267.
24. Phillips KA, Grant J, Siniscalchi JDJ, Albertini RS. Surgical and
nonpsychiatric medical treatment of patients with body
dysmorphic disorder. Psychosomatics 2001; 42: 504–510.
25. Crerand CE, Phillips KAW, Menard C, Fay BA. Nonpsychiatric
medical treatment of body dysmorphic disorder. Psychosomatics
2005; 46: 549–555.
26. Sarwer DB. Awareness and identification of body dysmorphic
disorder by aesthetic surgeons: results of a survey of American
Society for Aesthetic Plastic Surgery Members. Aesthetic Surg J
2002; 22: 531–535.
27. Lynn G v. Hugo. NY Int 68 2001; June 8.
28. Phillips KA. The Broken Mirror: Understanding and Treating Body
Dysmorphic Disorder. Oxford: Oxford University Press, 2005.

OralandMaxillofacialSurgery
The Maxillary Sinus: What the
General Dental Team Need to
Know Part 1: Paranasal Sinus
Physiology, Infective Disease and
Diagnosis of Pain
Enhanced CPD DO C
Abstract: This first paper of a four-part series guides the dental team through paranasal sinus physiology and how muco-ciliary clearance
is interrupted in disease, particularly infection. The role of acute rhinosinal infection is discussed in relation to orofacial pain and headache.
The broad differential diagnosis of what many patients regard as sinus-related pain is discussed, emphasizing the importance of the
patient history and clinical examination to reach a correct diagnosis and to avoid inappropriate antibiotic prescription or unnecessary
surgery.
CPD/Clinical Relevance: Many patients relate their chronic facial pain and headaches to disorders of their sinuses simply because the pain
overlies the location of the paranasal sinuses. Following diagnostic criteria, and application of such to reach an accurate diagnosis, will
improve patient care. Inter-specialty co-operation is essential in the management of chronic orofacial pain and headaches.
Dent Update 2020; 47: 314–325
Garmon W Bell Iain MacLeod James C Darcey Collin Campbell
Garmon W Bell, BDS, MSc, FDC RCS
FFD RCSI(OS), Associate Specialist Oral
and Maxillofacial Surgery, Dumfries and
Galloway Royal Infirmary, Iain MacLeod,
BDS, PhD, FDS RCS, FRCR, DDR RCR,
FHEA, Consultant and Senior Lecturer in
Dental and Maxillofacial Radiology and
Specialist in Oral Medicine, School of
Dental Sciences, Newcastle University,
and James C Darcey, BDS, MSc,
MDPH MFGDP, MEndo FDS(Rest Dent),
Consultant and Honorary Lecturer in
Restorative Dentistry and Specialist
in Endodontics, University Dental
Hospital of Manchester, and Collin
Campbell, BDS, FDS RCS, Specialist in
Oral Surgery with sub-specialty interest
in Implantology, The Campbell Clinic,
Nottingham, NG2 7JS, UK.
The paranasal sinuses have a unique and
multifunctional role in the upper respiratory
tract and base of the skull,1
and it is the
maxillary sinus that impacts most on the
role of the General Dental Practitioner
(GDP). The sinuses are thought to warm and
humidify inhaled air, and reduce the weight
of the facial skeleton. Increasingly, the
paranasal sinuses are recognized for the role
played in innate and adaptive immunity.1
In this first of four papers,
paranasal sinus physiology will be discussed
and how interruption of those physiological
processes, as a result of infection, contribute
to orofacial pain and very occasionally
headaches.
Paranasal sinus development
The paranasal sinuses are named after
the bones within which they lie develop
as epithelial outgrowths from the nasal
cavity. Named after the maxillary, ethmoid,
sphenoid and frontal bones, the location
and three-dimensional anatomy of the
paranasal sinuses in the adult are best
viewed in a colour atlas of cross-sectional
anatomy.
In the young child, the paranasal
sinuses are minimally developed. The
maxillary and ethmoid sinuses begin
development around the third month of
intra-uterine life, are present at birth, and
have reached almost full adult size by
puberty, although continue to pneumatize
the bones within which they lie throughout
life. The sphenoid sinuses develop after
birth, becoming pneumatized by the age
of five and, although they also reach adult
size by puberty, they continue to enlarge
through life. The frontal sinuses are the last
to develop as an out-budding from the

epithelium of the anterior ethmoid air cells,
only reaching full size by the late teenage
period.2
All of the sinuses drain into the
nasal cavity through epithelized channels
called ostia. The drainage of the maxillary
sinus is complicated in that the ostium
that opens into the nasal cavity is high up
on the medial wall, close to the orbit, such
that drainage has to occur against gravity.
The ethmoid and maxillary sinuses drain
into the middle meatus, below the middle
turbinate. The location of this is often
termed the osteo-meatal unit (Figure 1).
Paranasal sinus physiology
Historically, the paranasal sinuses were
thought to drain by gravity, and it was for
this reason that early treatment for infection
of the maxillary sinus in the pre-antibiotic
era often involved creating an antrostomy
as inferiorly as possible on the medial
wall of the sinus, on the lateral wall of the
nose below either the inferior or middle
turbinates.3,4
Surgical drainage of maxillary
sinus infection into the mouth through
an extraction site was also performed.5
The development of electron microscopy
increased understanding of cell function
and immunology changed that concept.
All paranasal sinuses, including
the nasal cavity, are lined with pseudo-
columnar ciliated epithelium, among
which is interspersed goblet cells and a
few sero-mucous salivary gland cells.6,7
It is the interactive role of the cilia and
the secretions of the goblet cells that
contributes to the special physiological
environment within the paranasal sinuses8
(Figure 2)
The goblet cells secrete a
complex blend of diverse glycoproteins
(mucins), lysozymes and lactoferrins,
alongside many other immune-modulating
factors, including cytokines.6-9
The mucin
layer sits on top of the liquid phase layer
which has a specific acid-base balance in
health for optimal function.10
Within the liquid phase layer
lie the cilia. The cilia, approximately 6μm
in length, have a unique internal structure
of dynein fibrils that enable controlled
movement.11
The cilia of the respiratory
epithelium beat in a synchronized motion,
usually at a rate of 10−20 times per second
in health, reducing to 5 or less in the
presence of infection or irritants.11
It is the combined action of the
cilia and the liquid/gel phase of the airway
surface layer that traps microbial organisms
and foreign bodies, propelling them to the
maxillary ostia for removal via muco-ciliary
clearance (Figure 1). The descriptive term
gel on water, or gel on a brush, has been
used to describe the interaction of the
cilia with the mucin and liquid phases of
the airway surface layer, which in health
moves at a rate of 10 mm per minute, often
against gravity and not in the most direct
route to the ostium.11
The rate is reduced
in disease. Impaired muco-ciliary clearance
contributes to stasis and infection, and may
arise through ciliary dyskinesia or changes
in mucous secretion.11
Primary ciliary
dyskinesia occurs through deranged protein
Figure 1. Coronal reconstruction of multi-slice computed tomographic image at location of osteo-
meatal unit demonstrating direction and pattern of muco-cilary clearance from ethmoid (green) and
maxillary sinuses (red).
Figure 2. Illustration demonstrating ciliary activity in conjunction with goblet cell secretions forming
the airway surface layer (ASL) to achieve muco-ciliary clearance of debris from paranasal sinus surface.

coding in the formation of the dynein fibrils,
usually as a result of genetic disease.11
Secondary ciliary dyskinesia is caused by
infection, or environmental influences.11
Diseases, such as cystic fibrosis, will produce
a mucous layer that becomes dehydrated,
shrinks and impinges on the underlying
serous layer, thereby impairing normal
ciliary movement.11,12
Excessive production
of mucous with an increased viscosity in
Chronic Obstructive Pulmonary Disease
(COPD) and asthma, as a result of goblet
cell metaplasia, also impedes normal ciliary
movement.10,11,13
From the perspective of the
Dental Team, impaired muco-ciliary
clearance, as a result of secondary ciliary
dyskinesia, arises when oral micro-
organisms move into the maxillary sinus,
or when dental materials are introduced.
The endotoxins produced by bacteria
impair normal ciliary activity.14
The impaired
muco-ciliary function, with or without oral
microbial contamination, will result in stasis
and lead to infection, usually bacterial or
fungal.11
Paranasal sinus infection
Paranasal sinus infection is classified as
either acute or chronic and may arise as
a result of viruses, bacteria and fungi. The
paranasal sinuses are self-cleansing air-
filled, humidified spaces, that in health have
a limited and balanced microbial flora.15,16
Acute paranasal sinusitis, usually
of viral aetiology, characteristically arises
a few days after the patient is recovering
from an acute upper respiratory tract
infection, most often, the common cold.
The characteristic biphasic presentation is
that of an individual who has just started
to feel better after 4−5 days of acute upper
respiratory symptoms, to relapse with acute
intense pain in the mid-face or frontal
area.17
When the maxillary sinus is involved,
patients may also complain of toothache.17
The acute sinusitis will usually
settle in one week, with or without
treatment. Guidelines recommend
symptom control with nasal decongestants,
topical steroids sprays and analgesia.17,18
Nasal decongestants should not be used
regularly for prolonged periods as rebound
mucosal oedema occurs when they are
stopped.19
Nasal douching with saline can
ease symptoms.20
Most cases of acute paranasal
sinus infection are of viral origin.17
Approximately 2% are of bacterial origin.17
The acute viral sinusitis should resolve in 10
days. If not, consideration should then be
given to the possibility of bacterial acute
sinusitis as a secondary infection.17
If there
is bacterial rhinosinal disease, the clinician
would expect the patient to report nasal
obstruction and purulent nasal discharge.
Systemic antibiotics are rarely required
unless the patient is pyrexic, or there
are other signs of spreading infection.17
Clinical guidelines provide evidence-based
recommendations relating to antibiotic
prescription.17,18,21,22
The antibiotic of choice
is co-amoxiclav. Second line antibiotics
are macrolides and tetracyclines.21,22
Radiological investigation is not indicated
unless there are signs of spreading
infection.17,23
Acute bacterial rhinosinal
disease in severe cases can present with
orbital and intracranial extension and the
clinical signs outlined in Table 1 would
alert the practitioner to this.24,25
Patients
presenting with infective complications, as
outlined above, will be clinically very unwell
and more inclined to contact their medical
rather than dental practitioner. However,
peri-orbital oedema from acute bacterial
infections of the ethmoids and maxillary
sinus can be similar to that arising from a
maxillary canine or lateral incisor tooth, and
for that reason patients may occasionally
contact their dental rather than medical
practitioner.
Chronic sinusitis is defined as
a symptom of nasal obstruction, facial
pressure or full purulent nasal discharge,
and hyposmia and occasionally anosmia
lasting for 12 or more weeks.17
It is usually of
bacterial or fungal aetiology, although can
also occur as a result of the immune system
response to fungal spores (fungal allergy).
Chronic rhinosinal disease is classified by
either the absence or presence of polypoid
tissue and there are specific treatment
guidelines for each.17
Polypoid tissue arises
because of the immunological response of
the nasal mucosa to irritants. Most polyps
arise in the ethmoid sinuses, with a smaller
proportion, usually antro-choanal, arising in
the maxillary sinus.26
Orofacial pain, including
odontogenic pain and headache, is rarely
a feature of chronic sinusitis except during
rare acute exacerbations of chronic sinus
infection.27
Recurrent acute rhinosinal
disease
Recurrent acute rhinosinal disease is
classified as four or more episodes of nasal
obstruction, purulent nasal discharge, with
facial pain or pressure-like symptoms per
year.17
Recurrent acute sinusitis is generally
regarded as being an exacerbation of
chronic rhinosinal disease.
infection can occur in the presence of
disease-modifying factors, such as asthma,
cystic fibrosis, ciliary dyskinesia, or immune
deficiency states. A patient presenting
 Reduced visual acuity
 Proptosis
 Ophthalmoplegia
 Peri-orbital oedema
 Diplopia
 Intense frontal headache
 Frontal bone swelling
 Altered consciousness or behaviour
 Focal neurological signs (of cranial nerves or hemiplegia)
 Seizures
Table 1. Signs of orbital and intracranial extension from acute bacterial rhinosinal disease.

with recurrent infection without an
obvious predisposing cause should be
investigated further.17
disease presents as a significant
healthcare burden in developed
countries with multiple work days
lost and repeat prescriptions of
antibiotics given,28
hence multiple
guidelines have been developed to
assist the practitioner in making an
accurate diagnosis.17,18,22,29
There is
now increasing doubt as to the real
prevalence of recurrent infective
acute rhinosinal disease, as there is
considerable overlap of symptoms
with primary headache syndromes
and orofacial pain.30,31,32
In addition,
there is an increased prevalence of
self-reported rhinosinal symptoms in
patients presenting with generalized
fatigue, chronic pain syndromes, non-
specific gastrointestinal symptoms,
and musculo-skeletal pain, suggestive
that some cases of recurrent rhinosinal
symptoms are of a functional rather
than organic nature.33-37
Establishing an accurate
diagnosis
With the aim of improving diagnosis,
guidelines recommend that, in
addition to the recognized descriptive
criteria for rhinosinal disease outlined
in Table 2, for a diagnosis of rhinosinal
disease there should also be:
 Direct anterior rhinological
endoscopic examination of the
middle meatus to determine if pus,
inflammatory mucosal changes with or
without polyps is identifiable;29
and/or
 Cross-sectional imaging, usually
computed tomography of the paranasal
sinuses.29
These specialist examinations
should only be undertaken in a specialist
setting by an Ear Nose and Throat (ENT)
surgeon. Cross-sectional imaging, even
in the specialist setting, is generally
reserved for cases of unilateral chronic
pain, or when there are symptoms or
signs suggestive of a sinister disease
process.17,38
Detailed description of clinical
findings upon anterior rhinoscopy is
beyond the scope of this paper, but is
well outlined in ENT texts.39
Computed
tomography of the paranasal sinuses is
performed to determine the presence or
absence of any signs of disease, including
inflammation within the paranasal
sinuses or adjacent tissues. Computed
tomography is also used to determine
the patency of the osteo-meatal complex,
where both the ethmoid and maxillary
sinuses drain into the nasal cavity40
(Figure 1).
The surgical management of
chronic rhinosinal disease is also beyond
the scope of this paper but interested
readers are directed to ENT texts.41
Non rhinosinal causes for
facial pain, headache and
dental pain
Patients with acute or chronic rhinosinal
disease do not necessarily have headache
or orofacial pain. This is demonstrated by
the following observations:
 Over 80% of patients observed to have
pus in the middle meatus upon anterior
rhinoscopy have no symptoms of pain;42
 Most patients with polyps in the
middle meatus do not experience pain;43
 A proportion of patients that
undergo surgical procedures for chronic
rhinosinal disease after failed medical
management continue to experience
pain post-operatively;42
 Up to 50% of patients having facial
radiographs taken for purposes other
than investigation of rhinosinal disease
demonstrated mucosal thickening
without symptoms;44
 Significant mucosal abnormalities
of the paranasal sinuses are identified
on CT and MR imaging performed for
reasons other than investigation of
rhinosinal disease in patients that have
no symptoms.45
Therefore, even if criteria
for a diagnosis of rhinosinal disease are
fulfilled, it does not necessarily follow
that their pain is solely attributable to
paranasal sinus infection. It has been
suggested that removing the symptom
of pain or pressure-like symptoms
from the diagnostic criteria allows for
greater specificity and sensitivity when
making a diagnosis of chronic rhinosinal
disease.46
At this stage, the criteria
on which a diagnosis of headache or
orofacial pain was based needs to be
re-considered, which in turn takes the
clinician back to the history of patient
symptoms and the wider differential
diagnosis of orofacial pain and
headaches.
Primary headaches:
migraine with autonomic
symptoms
The International Classification of
Headache Disorders recognizes
that rhinosinal disease and primary
headaches can co-exist in the same
patient and have variable contribution
to patient symptoms.47
The International
Headache Society also recognizes that
secondary headaches as a result of
acute rhinosinal disease are relatively
rare.47
It is now acknowledged that
many patients with unilateral facial pain
or a headache that present in the area of
the paranasal sinuses have migrainous
type headaches which can occur with
or without an aura.32,47,48
Migraine can
occur as mid-facial pressure without
Inflammation of nasal mucosa characterized by one or more symptoms which
should be:
1. Nasal obstruction or congestion
2. Nasal discharge with either anterior or posterior nasal drip
Additional criteria may include:
1. Facial pain or pressure-like sensation
2. Partial or complete loss of smell
Table 2. Current agreed criteria for an accurate description of rhinosinal disease.

headache, termed a typical aura
without headache.32,47
The clinical
picture is blurred even further when
it is recognized that some migraine-
type headaches can be bilateral.49
Parasympathetic stimulus to the sino-
nasal mucosa during a migraine may
cause oedema of nasal soft tissue, and
increase nasal secretions, although the
secretions would not be purulent.50
The parasympathetic stimulus will
therefore mimic the symptoms
stated by clinical guidelines as being
indicative of rhinosinal disease. It
would only be upon examination by
an ENT surgeon that polypoid disease or
purulent discharge in the middle meatus
could be excluded.
There is therefore a risk
that patients complaining of chronic
or recurrent facial pain and headaches,
with nasal discharge or congestion, may
fulfil the criteria outlined for diagnosis of
chronic or recurrent rhinosinal disease
and be started on an incorrect treatment
pathway when they have a primary
headache disorder.
There is evidence that patients
with facial pain or a headache without
purulent nasal discharge respond well
to triptan medication.51
However, the
clinical picture is further blurred when
it is recognized that some patients can
also experience migraines at the same
time as having symptoms related to
chronic rhinosinal disease.47,52
Primary headaches:
trigeminal autonomic
cephalgias
The trigeminal autonomic cephalgias,
recognized as primary headache
syndromes by the International
Headache Society, produce pain but,
because of parasympathetic activity,
also cause nasal congestion and nasal
discharge, in addition to lacrimation,
flushing of skin, conjunctival injection,
eyelid oedema and ptosis.47
Recurrent
attacks of facial pain and headaches,
caused by any of the trigeminal
autonomic cephalgias outlined in
Table 3, can be mistakenly diagnosed
as recurrent acute rhinosinal disease.
It is not possible to discuss trigeminal
autonomic cephalgias in detail in
this paper but interested readers are
referred to a further text.53
Trigeminal neuralgia
Although it would be unusual for
trigeminal neuralgia to be mistakenly
diagnosed as recurrent rhinosinal
disease, it has been reported.42
Trigeminal neuralgia has, on most
occasions, a very characteristic
unilateral presentation and is not
usually associated with any autonomic
symptoms that may cause nasal
obstruction or discharge. However, the
careful clinician would consider this as
part of a broader possible diagnosis in
cases where the clinical picture is not
clear.54
Temporomandibular
disorders: confusion with
rhinosinal disease
The clinician may experience
diagnostic difficulties when the patient
describes unilateral or bilateral facial
pain, with zygomatic/temporal or
retro-orbital radiation, especially when
the patient may describe many years of
facial pain and headache attributable
 Cluster headache
 Paroxysmal hemicrania
 SUNCT (short lasting neuralgiform headaches with conjunctival injection and tearing)
 SUNA (short lasting neuralgiform headaches with autonomic symptoms)
 Hemicrania continua
Table 3. Classification of trigeminal autonomic cephalgias.
Specific Sinogenic Shared Sinus and
Odontogenic
Specific Odontogenic
Unilateral nasal obstruction Increased pain with changes
in atmospheric pressure
(barodontalgia)
Increased pain upon
thermal stimuli when eating
or drinking
Unilateral nasal discharge Unilateral maxillary pain Obvious caries, or fracture
of tooth
Concurrent or recent upper
respiratory tract infection
Disturbed sleep Buccal or palatal swelling
directly adjacent to source
of pain
Increased pain on change in
vertical position of head
Facial swelling
(Rare cases of acute
ethmoid or frontal sinus
infection)
Specific radiological signs
Pus in middle meatus
(Specialist setting only)
Buccal sulcus swelling
(Will occur when maxillary
sinus very large with thin
lateral wall)
Tooth mobility
Heavily restored tooth
Inflamed or polypoid tissue
in middle meatus
Vertically fractured tooth
 Polarized light
transillumination
 Pain upon biting upon a
specific cusp
Table 4. Various symptoms and signs presenting suggestive of acute sinogenic or odontogenic pain.

to sinus disease. The problem is even
more challenging when other primary
care practitioners have reinforced the
incorrect diagnosis of rhinosinal disease
by multiple antibiotic prescriptions.
The diagnostic criteria for
acute or chronic rhinosinal disease
do not overlap with the diagnostic
criteria for temporomandibular disorder
(TMD).55
Careful history-taking from
a patient will determine whether or not
there is a history of nasal congestion,
nasal discharge, loss or reduction
of smell. Careful examination, as
outlined in the diagnostic criteria
for the most common pain-related
temporomandibular disorders, should
guide the clinician towards an accurate
diagnosis.55
Atypical facial pain or
tension type headache
In the absence of any specific patient
symptoms or clinical signs that would
suggest a specific disease process,
the diagnosis of atypical facial pain
or tension type headache should be
considered. Research has demonstrated
that non-specific, mid-facial pain was
caused by atypical facial pain, TMD and
tension type headaches as frequently
as migraines or trigeminal autonomic
cephalgias.42
Contact point headaches
There are multiple contributions to the
literature that aim to demonstrate that
various points of contact between the
medial and lateral nasal walls, including
contact of some of the turbinates with
either the medial or lateral nasal walls,
will contribute to areas of mucosal
pressure and cause headaches.56
Such
contact points are observed on CT
scanning.
While this topic has been
explored with vigour in the literature,
there is a paucity of reliable evidence to
support this concept. Mucosal contact
points have been demonstrated in
patients with and without symptoms
of pain.57
The concept risks exposing
patients to unnecessary radiation, and
also unnecessary surgery that will not
provide long-term control of symptoms.
Acute maxillary sinus pain or
odontogenic pain
The dental surgeon can be presented
with a patient complaining of acute
onset unilateral maxillary pain. As
for chronic or recurrent facial pain
and headache, the importance of a
comprehensive history of symptoms
cannot be under-estimated.
Clinical and radiological
examination as outlined in Table 4 will
guide the dental surgeon through the
diagnostic process of symptoms and
signs that are specific to acute infection
of the maxillary sinus or specific to
odontogenic disease. Some symptoms
and signs will be shared. Accurate
diagnosis will not be made on one sign
or symptom but rather a combination
of both.27
A periapical radiograph is
the image of choice for diagnosis. A
sectional dental panoramic tomogram
(DPT) may be used if the patient cannot
cope with a film holder. Radiological
signs suggestive of apical periodontitis
are; widening of periodontal ligament
space, loss of lamina dura around
apices, apical radioluency. Condensing
apical periodontitis is a sign rarely
observed in the posterior maxilla.
Gross or extensive secondary caries
are obvious signs suggestive of pulpal
necrosis.
There is no role for the use
of Cone Beam Computed Tomography
as a first line radiographic investigation
in the diagnosis of acute or chronic
orofacial pain.17,27,58
In the same context that
guidelines exist to enable accurate
diagnosis of chronic or recurrent
rhinosinal disease, in an effort to avoid
unnecessary antibiotic prescription
or surgery, an accurate diagnosis of
unilateral maxillary alveolar or facial
pain will hopefully avoid unnecessary
dental treatment.
Summary
This paper has discussed the diagnostic
criteria required for a diagnosis of either
acute or chronic rhinosinal disease,
to give the dental surgeon greater
confidence in making a diagnosis. The
potential for misdiagnosis of recurrent
or chronic orofacial, mid-facial pain,
with or without headaches, has been
emphasized.
It is recommended that the
dental surgeon who is unable to provide
a reliable diagnosis for mid-facial pain or
headache should refer to the patient’s
medical practitioner, or a secondary care
oral medicine/oral surgery/maxillofacial
surgery service.
The practice of prescribing
antibiotics in the presence of pain but
absence of specific signs of spreading
infection or pyrexia is discouraged.
It has not been possible for
this paper to provide an outline of all
paranasal sinus disease with a broad
pathogenic basis. This is covered in
more detail in other texts.1,7,9,27,39,40
The following three papers
will outline how dental care may impact
on the health, function and ultimately
disease of the maxillary sinus. In the
next paper the removal of teeth that are
closely related to the maxillary sinus,
and the possible complications that may
arise, will be discussed.
Conflict of Interest: The authors declare
that they have no conflict of interest.
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RestorativeDentistry
Is a Ridge Classification Helpful
when Assessing Edentulous
Patients?
Enhanced CPD DO C
Abstract: The edentulous ridge classifications most commonly used have their limitations in treatment planning. They do not provide an
indication of the complexities that may occur when constructing a new set of complete dentures. The new classification system suggested
in this article helps with improved record-keeping, information exchange between colleagues, and communication between patient and
clinician.
CPD/Clinical Relevance: The new edentulous ridge classification system links the various edentulous ridge shapes to possible
complications that could arise during denture construction.
Dent Update 2020; 47: 326–332
Kasim Butt and AD Walmsley
Wouter Leyssen, BDS, MJDF, MSc,
Specialty Dentist, Department of
Restorative Dentistry, Birmingham
Dental Hospital, Kasim Butt, BDS, MJDF,
PgCert Dent Ed, Specialty Registrar
in Restorative Dentistry, Charles
Clifford Dental Hospital, Sheffield
and AD Walmsley, PhD, MSc, BDS,
FDS RCPS, Professor and Director of
Internationalization, Head of Teaching
Unit of Prosthetic Dentistry, Birmingham
Dental Hospital, 5 Mill Pool Way,
Edgbaston, Birmingham B5 7EG, UK.
The Standards for Clinical Examination
and Record-Keeping (Faculty of General
Dental Practitioners UK) provides
guidance to clinicians on what should be
documented during history-taking and
a full examination. For patients seeking
removable prosthodontic treatment, it
is advised that an examination of the
denture-bearing tissues is undertaken,
noting presence of any tori, undercuts and
any other bony or soft tissue lesions.1
This
documented information should lead to
a clearly recorded diagnosis, treatment
option discussion and treatment plan
agreed with the patient. This process aids
clinicians in assessing the complexity of a
case and predicting any challenges that
they may encounter. For complete denture
construction it will allow the patient to
make an informed decision and reflect
on whether he/she finds that the benefits
of having new dentures outweigh any
potential disadvantages.
The assessment for complete
denture construction includes previous
denture-wearing history, assessment of
any available dentures, patient factors such
as the ability to adapt to dentures, and an
examination of the oral environment. In
this regard, the clinician should examine
the denture-bearing areas and note down
a description of the shape of the residual
ridge.2
This information is documented
as part of the clinical records and will be
part of the diagnosis as this will detail the
degree of resorption that has taken place
since the loss of the natural teeth. The
resorption pattern assists in understanding
the success of the final prosthesis. Although
there is no proven direct relationship
between ridge shape and success of
dentures, the initial description of the
ridge shape can be useful in discussions
as to why previous dentures may not have
been successful. The aim of this article is to
describe a modified approach to describing
edentulous ridge shapes with the objective
of aiding in communication between
colleagues, and as a tool to patients’
anticipated challenges in constructing
complete dentures, therefore managing
expectations.
Current ridge classifications
The ridge classifications proposed by
Atwood3
(Figure 1) or the modified version
of Cawood and Howell4
are intended to
provide a quantitative assessment of the
residual alveolar bone. However, it may
be argued that they have their limitations
in prosthodontic treatment planning. For
example, they fail to differentiate between
Wouter Leyssen

the bony support around teeth with an
intact periodontium and that of a patient
with a severe periodontally-compromised
dentition. Both cases would fall under
Atwood classification I. The treating
clinician would encounter very different
clinical challenges in each case where
complete denture construction is required.
An example includes clinical cases where
a clearance due to carious lesions/tooth
wear takes place, or where extractions are
due to periodontal attachment loss. In such
situations, very different ridge shapes may
remain following healing. Similarly, Atwood
classification II – a ridge immediately post
extraction – might inform about the quality
of the ridge but not about the quantity of
bone nor the ridge shape.
The Atwood, and Cawood and
Howell classifications do not provide an
indication of the complexities that may
occur when constructing a new set of
complete dentures. Atwood classification
III describes a well-rounded ridge form,
which is adequate in height and width. This
could be interpreted as a favourable ridge
anatomy. It does not take into account
those clinical situations where minimal
resorption has taken place. This lack of
bone resorption may create a challenge in
complete denture construction, as there will
be limited inter-ridge clearance.
Atwood classification V is
defined as a low well-rounded ridge. The
clinical management of patients with
Atwood ridge classification V and VI often
involve similar treatment. The mandibular
Atwood classification VI describes the ridge
as having a depressed ridge form, with
some basilar loss evident. This is not specific
enough and requires more detail. Atwood
classification VI represents a spectrum
of ridge shapes from a small central
depression with a bony buccal and lingual
ridge to partial or complete loss of the
lingual ridge. Extensive lingual resorption
leads to a complex ridge anatomy that is
difficult to treat, whereas a small central
depression does not necessarily require
a different clinical approach than that
which is normally employed for a ridge
classification V.
A new edentulous ridge
classification providing an accurate
description of the bony ridge shape
applicable to denture construction
therefore seems warranted. The ridge
shape could then be linked to any potential
problems which might be encountered
during denture construction. The new
classification described below could
help in treatment planning for denture
construction and potentially for the
planning of placement of implants.
New ridge classification
For new ridge classification see Figure 2.
Ridge Type 1
Definition: Unhealed ridge, the ridge shape
will change in the near future. Definitive
denture construction is not recommended.
Examples include, but are not limited to,
recent extraction sites, osteonecrosis
(Figure 3) or prolapsed antrum (Figure 4).
Ridge Type 2
Definition: No obvious resorption in height
and width – high profile and rounded
(Figures 5 and 6).
Impression-taking will seem
straightforward, however, the buccal sulcus
width is narrow and sometimes more difficult
to capture – especially with a spaced special
tray prescribed to deal with the (posterior)
bony undercuts. Impression material will
need to be elastic, such as alginate.
Denture construction may
be difficult due to the presence of bony
undercuts which prevent close adaptation of
the denture base in these deeper undercuts
to the denture-bearing area. The spacing
might break the seal and therefore lead to
loss of retention.
Buccal flanges in the anterior
segment will inevitably increase lip support.
Some patients prefer dentures with a ridge-
lapped design omitting the buccal flange.
The height of the ridges limits the space
available to construct dentures. There might
be difficulties obtaining sufficient freeway
space. The space available would need
to allow for a sufficient thickness of the
acrylic denture base and will limit the space
available for the crown height of the acrylic
teeth. This could lead to the need for setting
up small/short acrylic teeth onto the denture.
The positioning of the anterior
teeth might be another difficulty as they
would need to be set up on the crest of
the voluminous ridge. Failing this, in the
maxillary arch, the nasolabial angle would be
increased, affecting the facial profile.
Ridge Type 3
Definition: Some resorption of height and
width – high profile and rounded (Figures 7
and 8).
Impression-taking is
straightforward. Elastic and non-elastic
impression materials can be used, depending
on the presence of undercuts. There would
not be any specific issues to take into
consideration for denture construction
related to ridge anatomy.
Ridge Type 4
Definition: Some resorption of height and
more extensive loss of width at the crest of
Figure 1. Ridge classification according to Atwood.3

RT-1 Unhealed ridge (eg immediately post extraction,
osteonecrosis of the jaw) – permanent denture
construction not advised.
RT-2 No obvious resorption in height and width –
difficulties expected in denture construction related to
ridge anatomy.
RT-3 Some resorption of height and width (well-formed ridges)
- the ridge anatomy will not complicate
denture construction.
RT-4 Some resorption of height and more extensive loss
of width at the crest of ridge (knife edge) – the ridge
anatomy will not complicate denture
construction.
RT-5 Extensive loss of height maintaining a broad base. The
ridge might have a central depression – difficulties
expected in denture construction related to ridge
anatomy.
RT-6 Extensive loss of height with associated loss of width,
namely loss of the lingual bony ridge and loss of
the buccal shelf – the ridge anatomy makes denture
construction complex.
Figure 2. New ridge classification. RT Ridge Type.
Figure 3. Osteonecrosis. (Photo courtesy of Dr U
Patel).
Figure 4. Prolapsed antrum.
Figure 5. Ridge type 2 – Maxilla.
Figure 6. Ridge Type 2 – Mandible.
Figure 7. Ridge Type 3 – Maxilla.

Figure 8. Ridge Type 3 − Mandible.
the ridge - high profile knife edge (Figures
9 and 10).
Impression-taking is generally
uncomplicated and elastic or non-
elastic impression materials can be used.
A permanent resilient liner might be
indicated on the fit surface. Alternatively,
the laboratory could apply a tinfoil spacer
Figure 12. Ridge Type 5a – Mandible (flat with
string of soft tissue).
Figure 13. Ridge Type 5b – Mandible - central
depression palpable in posterior areas but not
clearly visible.
on the crest of the ridge on the master
cast before processing the denture (base).
Retention of the lower denture with this
ridge type may be inferior to Type 3 ridges.
This shape of ridge may mainly
be found in the anterior ridge of the
mandible and for patients who have worn
dentures for long periods of time.5,6
A
subdivision is suggested in the saw-tooth
ridge, the razor-like ridge and the ridge
with discrete large spiny projections. These
subdivisions are made on the radiographic
image of the ridge as they are often covered
by flabby soft tissue. As the radiographic
image of edentulous ridges is not always
available and X-ray imaging would not be
justified just on the basis of providing a
more precise classification, no subdivision
of ridge shape is suggested.
This ridge shape often leads to
complaints of pain, which presents as either
chronic or persistent soreness under the
denture, particularly during mastication.
Creating tin foil relief areas in the laboratory
over the painful regions will help to
distribute load over the denture-bearing
area. However, over time the soft tissues will
adapt and fill the relief space. The tissues
will then become traumatized as they are
trapped between the denture and sharp
bone. The patient should be warned that
such trauma could re-occur.5
Ridge Type 5a
Definition: Extensive loss of height
maintaining a broad base – low profile and
flat appearance (Figures 11 and 12)
Impression-taking will be more technique
sensitive. The use of a viscous impression
material for primary impressions is
recommended (eg heavy body silicone
or compound). Although there is no
evidence for the use of special trays, their
use is considered to be good practice.7
In the situation of a poor ridge form,
they are thought to decrease the risk of
over extension from occurring. Special
trays can more clearly indicate to the lab
the functional width and depth of the
sulcus. Impression material for the master
impression may be elastic (eg medium/light
body silicone) or non-elastic (eg zinc oxide
eugenol).
Another difficulty might be
that temporary bases used during jaw
registration are more likely to be displaced
during manipulation. In some cases, better
results can be achieved when heat-cured
acrylic bases are used.8,9
Ridge Type 5b (only for mandible)
Definition: Extensive loss of height
maintaining a broad base with a buccal and
lingual bony ridge and a central depression
– low profile and a central depression
(Figure 13).
For denture construction similar
principles apply as for classification 5a. The
clinical presentation is slightly different
as there is a central depression. This
does not affect the technique of denture
construction.
Ridge Type 6 (only for mandible)
Definition: Extensive loss of height with
associated loss of the lingual bony ridge
and loss of the buccal shelf – low profile
and narrow base (Figures 14 and 15).
Impression-taking is difficult as
there is only a narrow strip of keratinized
mucosa present. Primary impressions
are always over extended and the use of
viscous impression material is essential
to capture the mucosa covering the
remaining bony ridge. The soft tissues of

Figure 15. Ridge Type 6 – Mandible – tongue
raised.
Figure 16. Admix impression.
the floor of the mouth and the cheeks
tend to cover the denture-bearing area.
Special trays have a distinct shape and
ordinary impression materials could fail
to capture sufficient detail. Admix is one
of the few materials described for taking
impressions of this type of ridge (Figure
16). Admix consists of 3 parts by weight of
(red) impression compound to 7 parts by
weight of greenstick. The constituents are
placed into hot water and mixed together
by kneading with vaselined, gloved fingers.
Using a standard impression technique, the
lower impression is recorded. The working
time of this admix before it cools down
is 1–2 minutes.10
Most bases have some
over-extension. Some patients manage as
they have been denture-wearers for a long
time and they have adapted to the present
situation. Other patients will benefit from
implant placement to retain and/or support
the lower acrylic denture.11
Similar to classification 5, the
jaw registration might be more difficult to
complete due to unstable bases. The lower
dentures are often painful − even when a
permanent resilient lining is used − and
multiple review appointments are generally
needed to make the dentures comfortable.
This is no surprise as the only bony support
is provided by a sharp ridge surrounded by
high muscle attachments. This situation is
very unfavourable for conventional denture
construction.
Conclusion
It is sometimes difficult to describe ridge
anatomy accurately using the most
common ridge classifications available.
They have their limitations for treatment
planning and communication between
colleagues. The suggested new Ridge Type
classification not only clearly represents
the various edentulous ridge shapes
encountered during clinical practice, it also
relates them to possible complications that
could arise during denture construction.
To facilitate the transition to the new
classification system Ridge Type 3 and Ridge
Type 4 match the old classification systems.
Ridge Type 1 and 2 are not commonly
used in the previous classification and
5a, 5b and 6 are new additions which
would make the clinician alert to the new
classification system being used. The
improved record-keeping would facilitate
information exchange between colleagues
and communication between patient and
clinician and therefore dental universities
should consider adopting this classification
into their curriculum. The new classification
will be introduced at Birmingham Dental
Hospital during the academic year
2019/2020 and data collection regarding
the use of the new classification will be
undertaken subsequently.
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Faculty of General Dental Practitioners
(UK). Clinical Examination and Record-
Keeping 3rd edn 2016.
2. Patel J, Jablonski RY, Morrow LA.
Complete dentures: an update on
clinical assessment and management:
Part 1. Br Dent J 2018; 225: 707−714.
3. Atwood DA. Reduction of residual
ridges: a major oral disease entity.
J Prosthet Dent 1971; 26: 266−279.
4. Cawood JI, Howell RA. A classification
of the edentulous jaws. Int J Oral
Maxillofac Surg 1988; 17: 232−236.
5. Meyer RA. Management of denture
patients with sharp residual ridges.
J Prosthet Dent 1966; 16: 431−437.
6. Atwood DA. Clinical, cephalometric,
and densitometric study of reduction
of residual ridges. J Prosthet Dent 1971;
26: 280−295.
7. Critchlow SB, Ellis JS, Field JC. Reducing
the risk of failure in complete denture
patients. Dent Update 2012; 39:
427−436.
8. Gahan MJ, Walmsley AD. The neutral
zone impression revisited.
Br Dent J 2005; 198: 269−272.
9. Friel T. The anatomically difficult
denture case. Dent Update 2014; 41:
506−512.
10. McCord JF, Grant AA. Impression
making. Br Dent J 2000; 188: 484−492.
11. Thomason JM. The McGill consensus
statement on overdentures.
Mandibular 2-implant overdentures
as first choice standard of care for
edentulous patients. Eur J Prosthodont
Restor Dent 2002; 10: 95−96.
February 2020
1. C 6. B
2. C 7. A
3. D 8. A
4. C 9. C
5. D 10. B
CPD ANSWERS

PaediatricDentistry
Bitewing Radiography for Caries
Diagnosis in Children: When and
Why?
Enhanced CPD DO C
Laura Timms
Laura Timms, BDS, MFDS RCSEd, PGCert
DPH, ACF, Paediatric Dentistry, Charles
Clifford Dental Hospital, Wellesley
Road, Sheffield S10 2SZ, Chris Deery,
BDS, MSc, FDS RCSEd, PhD, FDS(Paed
Dent) RCS Ed, FDS RCSEng, FHEA
Dean, Professor/Honorary Consultant
in Paediatric Dentistry, Academic Unit
of Oral Health, Dentistry and Society,
School of Clinical Dentistry, University of
Sheffield, Claremont Crescent, Sheffield
S10 2TA, Barbara Chadwick, BDS,
MScD, PhD, FDS RCS(Edin), Professor/
Honorary Consultant in Paediatric
Dentistry, School of Dentistry Cardiff
University, Cardiff and Vale University
Health Board, Cardiff, CF14 4XY and
Nicholas Drage, BDS FDS RCS(Eng),
FDS RCPS(Glas), DRRCR, Consultant
in Dental and Maxillofacial Radiology,
University Dental Hospital, Cardiff and
Vale University Health Board, Cardiff,
CF14 4XY, UK.
Abstract: Untreated dental caries affects children in the UK, with significant burden to the child, family and health service. High quality
bitewing radiography is more effective than clinical observation alone at detecting proximal caries in children. Accurate diagnosis before
cavitation allows preventive rather than operative management. Research has demonstrated that most children find bitewing radiography
acceptable. It is therefore vital that bitewing radiographs of children are taken as per national guidance in general practice.
CPD/Clinical Relevance: Timely and high quality bitewing radiography is required for accurate diagnosis and treatment planning in
children.
Dent Update 2020; 47: 334–341
The 2013 Children’s Dental Health Survey
found that 31% of 5-year-olds had obvious
dietary advice and fluoride use to arrest
lesions. In both primary and permanent
teeth, between 33% and 100% of
caries lesions in the outer dentine are
cavitated, and the deeper the lesion has
penetrated dentine, the more likely it
is to have cavitated.6
If cavitation exists,
the efficiency of preventive treatment
is reduced, as removal of bacteria from
the cavity is difficult. In consequence,
more invasive treatment requiring local
or general anaesthesia may be necessary.
Further, in primary molars with proximal
caries, teeth are often pulpally involved at
an early stage, therefore early diagnosis
to allow restoration to avoid infection is
necessary.7
Diagnostic yield of bitewings
Kidd and Pitts’s 1990 literature review
concluded that bitewing radiography
is essential to ensure proximal caries is
not missed in the primary or permanent
dentition.8
Most studies included in the
review found that 50% more lesions were
detected compared to those identified
clinically, and that in some cases 250%
caries in the primary dentition.1
The average
number of decayed teeth was 0.9 but for
those with caries it was 3.0.1
Thirteen per
cent of 5-year-olds suffer from severe and
extensive decay, and 54% of 8-year-olds
had a mean of 1.1 primary teeth affected
by untreated caries into dentine, with
28% of 5-year-olds and 38% of 8-year-olds
having decay into dentine.1,2
The Care
Index indicates that the proportion of
carious teeth that are restored was 11.8%
in England for 5-year-olds in 2016–2017,
meaning only around 1 in 8 carious primary
teeth were treated.3
Caries is a burden for patients,
affecting confidence, sleeping and eating.4
When not treated, severe decay can lead
to pain and sepsis, and treatment under
general anaesthetic with associated
morbidity and mortality risks. It is also
a significant public health problem. In
2015/2016 there were 43,700 hospital
admissions of children under 16 with a
primary diagnosis of dental caries, mostly
requiring extractions.5
Detection of caries
before cavitation allows use of preventive
measures, such as oral hygiene instruction,
Chris Deery, Barbara Chadwick and Nicholas Drage

PaediatricDentistry
regarding proximal surfaces, bitewing
radiography will also demonstrate occlusal
caries once it has reached dentine. Weerheijm
et al in two separate studies found that, in the
permanent dentition in children, 15-37.5%
more occlusal lesions were detected where
bitewing radiography was employed.12,13
Similar findings were found by Newman
et al, where 12% more occlusal lesions
were detected with the use of bitewing
radiography.10
However, several other studies
have shown that bitewing radiography adds
little in the detection of occlusal lesions.14,15
In
a review by Braga et al it was suggested that,
if a thorough clinical examination was carried
out on cleaned dry teeth, then occlusal
lesions will not be missed.16
That being said,
whenever a bitewing radiograph has been
obtained it should always be examined for
occlusal caries in dentine.17
A study involving 126 children
in the primary dentition looked at the
effect on treatment planning of the
additional information provided by bitewing
radiograph by comparing treatment plans
based on clinical assessment alone, with
a treatment plan on the same patient
after assessment was supplemented with
bitewing radiography.18
The examiners
used a meticulous caries diagnostic system
(ICDAS). After use of bitewing radiography,
the number of surfaces that changed from
no treatment, to non-operative management,
and to operative management increased.
While the overall percentage increase was
small, this has to be taken in context, as the
authors considered all surfaces, including
occlusal ones, when caries in the primary
dentition is centred on the approximal
surfaces, particularly the distal surface of the
first primary molar and the mesial surface
of the second primary molar. Therefore, the
percentage increase for clinically important
(approximal) surfaces may well have been
greater. This is reflected in the fact that
a greater effect was seen for proximal
surfaces. Fifty-two (3.2%) surfaces believed
sound moved into requiring non-operative
treatment and 46 (2.8%), moved to
requiring operative care, as did 50 (6.2%)
of surfaces originally thought amenable
to prevention. Therefore, the additional
diagnostic information available following
bitewing radiographic examination altered
a significant number of treatment plans.
Specificity of bitewing radiography has
been found to be high, at over 90%,
therefore the rate of false positives and over
treatment would be low.10
Caries risk
A patient’s caries risk should be determined
following thorough history-taking
(including medical, social and dental) and
examination, thus requiring accurate caries
diagnosis. In children, caries experience
is the single best predictor for future
caries development, but the findings of
a recent systematic review and a review
of longitudinal studies have shown that
other factors may be useful, including at
a sociodemographic/socioeconomic level,
dietary habits, oral hygiene, fluoride use,
presence of lactobacilli/Streptococci mutans,
salivary flow rate and the post-eruptive
age.19–21
Using these risk factors, patients
can be categorized into very high, high, and
low caries risk, with preventive treatment
tailored appropriately.22
The additional
diagnostic yield from bitewing radiography
is higher in the high-risk groups and lower
in the low-risk groups.23
Bitewing interval guidelines
The Faculty of General Dental Practice UK
(FGDP) have recommended appropriate
time intervals between bitewing
Figure 1. (a) Clinical view showing an apparently
caries-free lower dentition. (b) Radiographs of
the same child showing distal dentine caries in
both lower first primary molars and enamel caries
lower right second primary molar.
a
b
more lesions could be detected from
bitewings. A more recent systematic literature
review also confirmed that, for proximal
surfaces, the radiographic prevalence of
carious lesions was considerably higher than
clinical prevalence.9
Further, Newman et al
found that 48% more proximal carious lesions
were diagnosed with bitewing radiography
than without. Bitewing radiography is
considered particularly important in
diagnosing early proximal lesions, allowing
the possibility for preventive intervention.10,11
Figures 1a and 1b show an apparently
caries-free lower arch. However, radiographs
reveal distal dentine caries in the lower first
primary molars and enamel caries in the
mesial surface of the lower right second
primary molar. There is a slight shadow visible
through the marginal ridge of the lower
left first primary molar. This is a result of the
camera flash and was not seen clinically.
As well as providing information
Risk Category Recommendation
High Risk 6-monthly posterior bitewings until no active lesions are
apparent and the individual has entered another risk category
Moderate Risk Annual bitewings until no active lesions are apparent and the
individual has entered another risk category
Low Risk 12−18 monthly bitewings in the primary dentition and at 2-year
intervals in the permanent dentition
Table 1. FGDP UK Guidelines on Bitewing Radiography in Children.23

Other documents randomly have
different content

dirhems, stamped at Samarkand, Balkh, Merv, &c., were also found
in 1869.
In 1862 the population of Kiev was returned as 70,341; in 1874
the total was given as 127,251; and in 1902 as 319,000. This
includes 20,000 Poles and 12,000 Jews. Kiev is the headquarters of
the IX. Army Corps, and of a metropolitan of the Orthodox Greek
Church.
The history of Kiev cannot be satisfactorily separated from
that of Russia. According to Nestor’s legend it was founded in
864 by three brothers, Kiy, Shchek and Khoriv, and after their
deaths the principality was seized by two Varangians
(Scandinavians), Askold and Dir, followers of Rurik, also in 864.
Rurik’s successor Oleg conquered Kiev in 882 and made it the
chief town of his principality. It was in the waters of the Dnieper
opposite the town that Prince Vladimir, the first saint of the
Russian church, caused his people to be baptized (988), and
Kiev became the seat of the first Christian church, of the first
Christian school, and of the first library in Russia. For three
hundred and seventy-six years it was an independent Russian
city; for eighty years (1240-1320) it was subject to the Mongols;
for two hundred and forty-nine years (1320-1569) it belonged to
the Lithuanian principality; and for eighty-five years to Poland
(1569-1654). It was finally united to the Russian empire in 1686.
The city was devastated by the khan of the Crimea in 1483. The
Magdeburg rights, which the city enjoyed from 1516, were
abolished in 1835, and the ordinary form of town government
introduced; and in 1840 it was made subject to the common civil
law of the empire.

The Russian literature concerning Kiev is voluminous. Its
bibliography will be found in the Russian Geographical Dictionary
of P. Semenov, and in the Russian Encyclopaedic Dictionary,
published by Brockhaus and Efron (vol. xv., 1895). Among recent
publications are: Rambaud’s La Russie épique (Pans, 1876);
Avenarius, Kniga o Kievskikh Bogatuiryakh (St Petersburg,
1876), dealing with the early Kiev heroes; Zakrevski, Opisanie
Kieva (1868); the materials issued by the commission for the
investigation of the ancient records of the city; Taranovskiy,
Gorod Kiev (Kiev, 1881); De Baye, Kiev, la mère des villes russes
(Paris, 1896); Goetz, Das Kiewer Höhlenkloster als
Kulturzentrum des Vormongolischen Russlands (Passau, 1904).
See also Count Bobrinsky, Kurgans of Smiela (1897); and N.
Byelyashevsky, The Mints of Kiev. (P. A. K.; J. T. Be.)
KILBARCHAN, a burgh of barony of Renfrewshire, Scotland,
1 m. from Milliken Park station on the Glasgow & South-Western
railway, 13 m. W. by S. of Glasgow. Pop. (1901), 2886. The public
buildings include a hall, library and masonic lodge (dating from
1784). There is also a park. In a niche in the town steeple (erected
in 1755) is the statue of the famous piper, who died about the
beginning of the 17th century and is commemorated in the elegy on
“The Life and Death of Habbie Simson, Piper of Kilbarchan” by
Robert Sempill of Beltrees (1595-1665). The chief industries are

manufactures of linen (introduced in 1739 and dating the rise of the
prosperity of the town), cotton, silks and “Paisley” shawls, and
calico-printing, besides quarries, coal and iron mines in the
neighbourhood. Two miles south-west is a great rock of greenstone
called Clochoderick, 12 ft. in height, 22 ft. in length, and 17 ft. in
breadth. About 2 m. north-west on Gryfe Water, lies Bridge of Weir
(pop. 2242), the industries of which comprise tanning, currying,
calico-printing, thread-making and wood-turning. It has a station on
the Glasgow & South-Western railway. Immediately to the south-
west of Bridge of Weir are the ruins of Ranfurly Castle, the ancient
seat of the Knoxes. Sir John de Knocks (fl. 1422) is supposed to
have been the great-grandfather of John Knox; and Andrew Knox
(1550-1633), one of the most distinguished members of the family,
was successively bishop of the Isles, abbot of Icolmkill (Iona), and
bishop of Raphoe. About 4 m. N.W. of Bridge of Weir lies the holiday
resort of Kilmalcolm (pronounced Kilmacome; pop. 2220), with a
station on the Glasgow & South-Western railway. It has a golf-
course, public park and hydropathic establishment. Several
charitable institutions have been built in and near the town, amongst
them the well-known Quarrier’s Orphan Homes of Scotland.
KILBIRNIE, a town in north Ayrshire, Scotland, on the
Garnock, 20½ m. S.W. of Glasgow, with stations on the Glasgow &
South-Western and the Caledonian railways. Pop. (1901), 4571. The

industries include flax-spinning, rope works, engineering works, and
manufactures of linen thread, wincey, flannels and fishing-nets, and
there are iron and steel works and coal mines in the vicinity. The
parish church is of historical interest, most of the building dating
from the Reformation. In the churchyard are the recumbent effigies
of Captain Thomas Crawford of Jordanhill (d. 1603), who in 1575
effected the surprise of Dumbarton Castle, and his lady. Near
Kilbirnie Place, a modern mansion, are the ruins of Kilbirnie Castle,
an ancient seat of the earls of Crawford, destroyed by fire in 1757.
About 1 m. E. is Kilbirnie Loch, 11⁄3 m. long.
KILBRIDE, WEST, a town on the coast of Ayrshire, Scotland,
near the mouth of Kilbride Burn, 4 m. N.N.W. of Ardrossan and 35¾
m. S.W. of Glasgow by the Glasgow & South-Western railway. Pop.
(1901), 2315. It has been growing in repute as a health resort; the
only considerable industry is weaving. In the neighbourhood are the
ruins of Law Castle, Crosbie Castle and Portincross Castle, the last,
dating from the 13th century, said to be a seat of the Stuart kings.
Farland Head, with cliffs 300 ft. high, lies 2 m. W. by N.; and the
inland country is hilly, one point, Kaim Hill, being 1270 ft. above sea-
level.

KILDARE, a county of Ireland in the province of Leinster,
bounded W. by Queen’s County and King’s County, N. by Meath, E.
by Dublin and Wicklow, and S. by Carlow. The area is 418,496 acres
or about 654 sq. m. The greater part of Kildare belongs to the great
central plain of Ireland. In the east of the county this plain is
bounded by the foot-hills of the mountains of Dublin and Wicklow; in
the centre it is interrupted by an elevated plateau terminated on the
south by the hills of Dunmurry, and on the north by the Hill of Allen
(300 ft.) which rises abruptly from the Bog of Allen. The principal
rivers are the Boyne, which with its tributary the Blackwater rises in
the north part of the county, but soon passes into Meath; the
Barrow, which forms the boundary of Kildare with Queen’s County,
and receives the Greese and the Lane shortly after entering Kildare;
the Lesser Barrow, which flows southward from the Bog of Allen to
near Rathangan; and the Liffey, which enters the county near
Ballymore Eustace, and flowing north-west and then north-east quits
it at Leixlip, having received the Morrel between Celbridge and
Clane, and the Ryewater at Leixlip. Trout are taken in the upper
waters, and there are salmon reaches near Leixlip.
Geology.—The greater part of the county is formed of typical
grey Carboniferous limestone, well seen in the flat land about
Clane. The natural steps at the Salmon Falls at Leixlip are
formed from similar strata. Along the south-east the broken

ground of Silurian shales forms the higher country, rising
towards the Leinster chain. The granite core of the latter, with
its margin of mica-schist produced by the metamorphism of the
Silurian beds, appears in the south round Castledermot. A
parallel ridge of Silurian rocks, including an interesting series of
basic lavas, rises from the plain north of Kildare town (Hill of
Allen and Chair of Kildare), with some Old Red Sandstone on its
flanks. The limestone in this ridge is rich in fossils of Bala age,
and has been compared with that at Portrane in county Dublin.
The low ground is diversified by eskers and masses of glacial
gravel, notably at the dry sandy plateau of the Curragh; but in
part it retains sufficient moisture to give rise to extensive bogs.
The Liffey, which comes down as a mountain-stream in the
Silurian area, forming a picturesque fall in the gorge of
Pollaphuca, wanders through the limestone region between low
banks as a true river of the plain.
Climate and Industries.—Owing to a considerable degree to
the large extent of bog, the climate of the northern districts is
very moist, and fogs are frequent, but the eastern portion is
drier, and the climate of the Liffey valley is very mild and
healthy. The soil, whether resting on the limestone or on the
clay slate, is principally a rich deep loam inclining occasionally to
clay, easily cultivated and very fertile if properly drained. About
40,000 acres in the northern part of the county are included in
the Bog of Allen, which is, however, intersected in many places
by elevated tracts of firm ground. To the east of the town of
Kildare is the Curragh, an undulating down upwards of 4800
acres in extent. The most fertile and highly cultivated districts of
Kildare are the valleys of the Liffey and a tract in the south
watered by the Greese. The demesne lands along the valley of

the Liffey are finely wooded. More attention is paid to drainage
and the use of manures on the larger farms than is done in
many other parts of Ireland. The pastures which are not
subjected to the plough are generally very rich and fattening.
The proportion of tillage to pasture is roughly as 1 to 2½.
Wheat is a scanty crop, but oats, barley, turnips and potatoes
are all considerably cultivated. Cattle and sheep are grazed
extensively, and the numbers are well sustained. Of the former,
crosses with the shorthorn or the Durham are the commonest
breed. Leicesters are the principal breed of sheep. Poultry
farming is a growing industry.
Though possessing a good supply of water-power the county
is almost destitute of manufactures; there are a few small
cotton, woollen and paper mills, as well as breweries and
distilleries, and several corn mills. Large quantities of turf are
exported to Dublin by canal. The main line of the Midland Great
Western follows the northern boundary of the county, with a
branch to Carbury and Edenderry; and that of the Great
Southern & Western crosses the county by way of Newbridge
and Kildare, with southward branches to Naas (and Tullow,
county Carlow) and to Athy and the south. The northern border
is traversed by the Royal Canal, which connects Dublin with the
Shannon at Cloondara. Farther south the Grand Canal, which
connects Dublin with the Shannon at Shannon Harbour, occupies
the valley of the Liffey until at Sallins it enters the Bog of Allen,
passing into King’s County near the source of the Boyne. Several
branch canals afford communication with the southern districts.
Population and Administration.—The decreasing population
(70,206 in 1891; 63,566 in 1901) shows an unusual excess of males

over females, in spite of an excess of male emigrants. About 86% of
the population are Roman Catholics. The county comprises 14
baronies and contains 110 civil parishes. Assizes are held at Naas,
and quarter sessions at Athy, Kildare, Maynooth and Naas. The
military stations at Newbridge and the Curragh constitute the
Curragh military district, and the barracks at Athy and Naas are
included in the Dublin military district. The principal towns are Athy
(pop. 3599), Naas (3836) and Newbridge (2903); with Maynooth
(which is the seat of a Roman Catholic college), Celbridge, Kildare
(the county town), Monasterevan, Kilcullen and Leixlip. Ballitore, one
of the larger villages, is a Quaker settlement, and at a school here
Edmund Burke was educated. Kildare returned ten members to the
Irish parliament, of whom eight represented boroughs; it sends only
two (for the north and south divisions of the county) to the
parliament of the United Kingdom. The county is in the Protestant
diocese of Dublin and the Roman Catholic dioceses of Dublin and of
Kildare and Leighlin.
History and Antiquities.—According to a tale in the Book of
Leinster the original name of Kildare was Druim Criaidh (Drumcree),
which it retained until the time of St Brigit, after which it was
changed to Cilldara, the church of the oak, from an old oak under
whose shadow the saint had constructed her cell. For some
centuries it was under the government of the Macmurroughs, kings
of Leinster, but with the remainder of Leinster it was granted by
Henry II. to Strongbow. On the division of the palatinate of Leinster
among the five grand-daughters of Strongbow, Kildare fell to Sibilla,
the fourth daughter, who married William de Ferrars, earl of Derby.
Through the marriage of the only daughter of William de Ferrars it
passed to William de Vescy—who, when challenged to single combat
by John Fitz Thomas, baron of Offaly, for accusing him of treason,

fled to France. His lands were thereupon in 1297 bestowed on Fitz
Thomas, who in 1316 was created earl of Kildare, and in 1317 was
appointed sheriff of Kildare, the office remaining in the family until
the attainder of Gerald, the ninth earl, in the reign of Henry VIII.
Kildare was a liberty of Dublin until 1296, when an act was passed
constituting it a separate county.
In the county are several old gigantic pillar-stones, the principal
being those at Punchestown, Harristown, Jigginstown and
Mullamast. Among remarkable earthworks are the raths at
Mullamast, Knockcaellagh near Kilcullen, Ardscull near Naas, and the
numerous sepulchral mounds in the Curragh. Of the round towers
the finest is that of Kildare; there are remains of others at Taghadoe,
Old Kilcullen, Oughterard and Castledermot. Formerly there were an
immense number of religious houses in the county. There are
remains of a Franciscan abbey at Castledermot. At Graney are ruins
of an Augustinian nunnery and portions of a building said to have
belonged to the Knights Templars. The town of Kildare has ruins of
four monastic buildings, including the nunnery founded by St Brigit.
The site of a monastery at Old Kilcullen, said to date from the time
of St Patrick, is marked by two stone crosses, one of which is
curiously sculptured. The fine abbey of Monasterevan is now the
seat of the marquess of Drogheda. On the Liffey are the remains of
Great Connel Abbey near Celbridge, of St Wolstan’s near Celbridge,
and of New Abbey. At Moone, where there was a Franciscan
monastery, are the remains of an ancient cross with curious
sculpturings. Among castles may be mentioned those of Athy and
Castledermot, built about the time of the Anglo-Norman invasion;
Maynooth Castle, built by the Fitzgeralds; Kilkea, originally built by
the seventh earl of Kildare, and restored within the 19th century;
and Timolin, erected in the reign of King John.

KILDARE, a market town and the county town of county
Kildare, Ireland, in the south parliamentary division, a junction on
the main line of the Great Southern & Western railway, 30. m. S.W.
from Dublin, the branch line to Athy, Carlow and Kilkenny diverging
southward. Pop. (1901), 1576. The town is of high antiquarian
interest. There is a Protestant cathedral church, the diocese of which
was united with Dublin in 1846. St Brigit or Bridget founded the
religious community in the 5th century, and a fire sacred to the
memory of the saint is said to have been kept incessantly burning
for several centuries (until the Reformation) in a small ancient chapel
called the Fire House, part of which remains. The cathedral suffered
with the town from frequent burnings and destructions at the hands
of the Danes and the Irish, and during the Elizabethan wars. The
existing church was partially in ruins when an extensive restoration
was begun in 1875 under the direction of G.E. Street; while the
choir, which dated from the latter part of the 17th century, was
rebuilt in 1896. Close to the church are an ancient cross and a very
fine round tower (its summit unhappily restored with a modern
battlement) 105½ ft. high, with a doorway with unusual ornament
of Romanesque character. There are remains of a castle of the 13th
century, and of a Carmelite monastery. From the elevated situation
of the town, a striking view of the great central plain of Ireland is

afforded. Kildare was incorporated by James II., and returned two
members to the Irish parliament.
KILHAM, ALEXANDER (1762-1798), English Methodist,
was born at Epworth, Lincolnshire, on the 10th of July 1762. He was
admitted by John Wesley in 1785 into the regular itinerant ministry.
He became the leader and spokesman of the democratic party in the
Connexion which claimed for the laity the free election of class-
leaders and stewards, and equal representation with ministers at
Conference. They also contended that the ministry should possess
no official authority or pastoral prerogative, but should merely carry
into effect the decisions of majorities in the different meetings.
Kilham further advocated the complete separation of the Methodists
from the Anglican Church. In the violent controversy that ensued he
wrote many pamphlets, often anonymous, and frequently not in the
best of taste. For this he was arraigned before the Conference of
1796 and expelled, and he then founded the Methodist New
Connexion (1798, merged since 1906 in the United Methodist
Church). He died in 1798, and the success of the church he founded
is a tribute to his personality and to the principles for which he
strove. Kilham’s wife (Hannah Spurr, 1774-1832), whom he married
only a few months before his death, became a Quaker, and worked
as a missionary in the Gambia and at Sierra Leone; she reduced to
writing several West African vernaculars.

KILIA, a town of S. Russia, in the government of Bessarabia,
100 m. S.W. of Odessa, on the Kilia branch of the Danube, 20 m.
from its mouth. Pop. (1897), 11,703. It has steam flour-mills and a
rapidly increasing trade. The town, anciently known as Chilia, Chele,
and Lycostomium, was a place of banishment for political dignitaries
of Byzantium in the 12th-13th centuries. After belonging to the
Genoese from 1381-1403 it was occupied successively by Walachia
and Moldavia, until in 1484 it fell into the hands of the Ottoman
Turks. It was taken from them by the Russians in 1790. After being
bombarded by the Anglo-French fleet in July 1854, it was given to
Rumania on the conclusion of the war; but in 1878 was transferred
to Russia with Bessarabia.
KILIAN (Chilian, Killian), ST, British missionary bishop and the
apostle of eastern Franconia, where he began his labours towards
the end of the 7th century. There are several biographies of him, the
first of which dates back to the 9th century (Bibliotheca

hagiographica latina, Nos. 4660-4663). The oldest texts which refer
to him are an 8th century necrology at Würzburg and the notice by
Hrabanus Maurus in his martyrology. According to Maurus, Kilian was
a native of Ireland, whence with his companions he went to eastern
Franconia. After having preached the gospel in Würzburg, the whole
party were put to death by the orders of an unjust judge named
Gozbert. It is difficult to fix the period with precision, as the judge
(or duke) Gozbert is not known through other sources. Kilian’s
comrades, Coloman and Totman, were, according to the Würzburg
necrology, respectively priest and deacon. The elevation of the relics
of the three martyrs was performed by Burchard, the first bishop of
Würzburg, and they are venerated in the cathedral of that town. His
festival is celebrated on the 8th of July.
See Acta Sanctorum, Julii, ii. 599-619; F. Emmerich, Der
heilige Kilian (Würzburg, 1896); J. O’Hanlon, Lives of the Irish
Saints, vii. 122-143 (Dublin, 1875-1904); A. Hauck,
Kirchengeschichte Deutschlands, 3rd ed., i. 382 seq.
(H. De.)
KILIMANJARO, a great mountain in East Africa, its centre
lying in 3° 5′ S. and 37° 23′ E. It is the highest known summit of the
continent, rising as a volcanic cone from a plateau of about 3000 ft.
to 19,321 ft. Though completely isolated it is but one of several
summits which crown the eastern edge of the great plateau of

equatorial Africa. About 200 m. almost due north, across the wide
expanse of the Kapte and Kikuyu uplands, lies Mount Kenya,
somewhat inferior in height and mass to Kilimanjaro; and some 25
m. due west rises the noble mass of Mount Meru.
The major axis of Kilimanjaro runs almost east and west, and on it
rise the two principal summits, Kibo in the west, Mawenzi (Ki-
mawenzi) in the east. Kibo, the higher, is a truncated cone with a
nearly perfect extinct crater, and marks a comparatively recent
period of volcanic activity; while Mawenzi (16,892 ft.) is the very
ancient core of a former summit, of which the crater walls have been
removed by denudation. The two peaks, about 7 m. apart, are
connected by a saddle or plateau, about 14,000 ft. in altitude, below
which the vast mass slopes with great regularity in a typical volcanic
curve, especially in the south, to the plains below. The sides are
furrowed on the south and east by a large number of narrow
ravines, down which flow streams which feed the Pangani and Lake
Jipe in the south and the Tsavo tributary of the Sabaki in the east.
South-west of Kibo, the Shira ridge seems to be of independent
origin, while in the north-west a rugged group of cones, of
comparatively recent origin, has poured forth vast lava-flows. In the
south-east the regularity of the outline is likewise broken by a ridge
running down from Mawenzi.
The lava slopes of the Kibo peak are covered to a depth of some
200 ft. with an ice-cap, which, where ravines occur, takes the form
of genuine glaciers. The crater walls are highest on the south, three
small peaks, uncovered by ice, rising from the rim on this side. To
the central and highest of these, the culminating point of the
mountain, the name Kaiser Wilhelm Spitze has been given. The rim
here sinks precipitously some 600 ft. to the interior of the crater,

which measures rather over 2000 yds. in diameter, and is in part
covered by ice, in part by a bare cone of ashes. On the west the rim
is breached, allowing the passage of an important glacier formed
from the snow which falls within the crater. Lower down this cleft,
which owed its origin to dislocation, is occupied by two glaciers, one
of which reaches a lower level (13,800 ft.) than any other on
Kilimanjaro. On the north-west three large glaciers reach down to
16,000 ft.
Mawenzi peak has no permanent ice-cap, though at times snow
lies in patches. The rock of which it is composed has become very
jagged by denudation, forming stupendous walls and precipices. On
the east the peak falls with great abruptness some 6500 ft. to a vast
ravine, due apparently to dislocation and sinking of the ground.
Below this the slope is more gradual and more symmetrical. Like the
other high mountains of eastern Africa, Kilimanjaro presents well-
defined zones of vegetation. The lowest slopes are arid and scantily
covered with scrub, but between 4000 and 6000 ft. on the south
side the slopes are well watered and cultivated. The forest zone
begins, on the south, at about 6500 ft., and extends to 9500, but in
the north it is narrower, and in the north-west, the driest quarter of
the mountain, almost disappears. In the alpine zone, marked
especially by tree lobelias and Senecio, flowering plants extend up to
15,700 ft. on the sheltered south-west flank of Mawenzi, but
elsewhere vegetation grows only in dwarfed patches beyond 13,000
ft. The special fauna and flora of the upper zone are akin to those of
other high African mountains, including Cameroon. The southern
slopes, between 4000 and 6000 ft., form the well-peopled country of
Chaga, divided into small districts.

As the natives believe that the summit of Kilimanjaro is
composed of silver, it is conjectured that Aristotle’s reference to
“the so-called Silver Mountain” from which the Nile flows was
based on reports about this mountain. It is possible, however,
that the “Silver Mountain” was Ruwenzori (q.v.), from whose
snow-clad heights several headstreams of the Nile do descend.
It is also possible, though improbable, that Ruwenzori and not
Kilimanjaro nor Kenya may be the range known to Ptolemy and
to the Arab geographers of the middle ages as the Mountains of
the Moon. Reports of the existence of mountains covered with
snow were brought to Zanzibar about 1845 by Arab traders.
Attracted by these reports Johannes Rebmann of the Church
Missionary Society journeyed inland from Mombasa in 1848 and
discovered Kilimanjaro, which is some 200 m. inland. Rebmann’s
account, though fully borne out by his colleague Dr Ludwig
Krapf, was at first received with great incredulity by professional
geographers. The matter was finally set at rest by the visits paid
to the mountain by Baron Karl von der Decken (1861 and 1862)
and Charles New (1867), the latter of whom reached the lower
edge of the snow. Kilimanjaro has since been explored by
Joseph Thomson (1883), Sir H. H. Johnston (1884), and others.
It has been the special study of Dr Hans Meyer, who made four
expeditions to it, accomplishing the first ascent to the summit in
1889. In the partition of Africa between the powers of western
Europe, Kilimanjaro was secured by Germany (1886) though the
first treaties concluded with native chiefs in that region had been
made in 1884 by Sir H. H. Johnston on behalf of a British
company. On the southern side of the mountain at Moshi is a
German government station.

See R. Thornton (the geologist of von der Decken’s party) in
Proc. of Roy. Geog. Soc. (1861-1862); Ludwig Krapf, Travels in
East Africa (1860); Charles New, Life ... in East Africa (1873); Sir
J. D. Hooker in Journal of Linnean Society (1875); Sir H. H.
Johnston, The Kilimanjaro Expedition (1886); Hans Meyer,
Across East African Glaciers (1891); Der Kilimanjaro (Berlin,
1900). Except the last-named all these works were published in
London. (E. He.)
KILIN, or Ch’-i-lin, one of the four symbolical creatures which in
Chinese mythology are believed to keep watch and ward over the
Celestial Empire. It is a unicorn, portrayed in Chinese art as having
the body and legs of a deer and an ox’s tail. Its advent on earth
heralds an age of enlightened government and civic prosperity. It is
regarded as the noblest of the animal creation and as the
incarnation of fire, water, wood, metal and earth. It lives for a
thousand years, and is believed to step so softly as to leave no
footprints and to crush no living thing.

KILKEE, a seaside resort of county Clare, Ireland, the terminus
of a branch of the West Clare railway. Pop. (1901), 1661. It lies on a
small and picturesque inlet of the Atlantic named Moore Bay, with a
beautiful sweep of sandy beach. The coast, fully exposed to the
open ocean, abounds in fine cliff scenery, including numerous caves
and natural arches, but is notoriously dangerous to shipping. Moore
Bay is safe and attractive for bathers. Bishop’s Island, a bold isolated
rock in the vicinity, has remains of an oratory and house ascribed to
the recluse St Senan.
KILKENNY, a county of Ireland, in the province of Leinster,
bounded N. by Queen’s County, E. by Carlow and Wexford, S. by
Waterford, and W. by Waterford and Tipperary. The area is 511,775
acres, or about 800 sq. m. The greater part of Kilkenny forms the
south-eastern extremity of the great central plain of Ireland, but in
the south-east occurs an extension of the mountains of Wicklow and
Carlow, and the plain is interrupted in the north by a hilly region

forming part of the Castlecomer coal-field, which extends also into
Queen’s County and Tipperary. The principal rivers, the Suir, the
Barrow and the Nore, have their origin in the Slieve Bloom
Mountains (county Tipperary and Queen’s County), and after widely
divergent courses southward discharge their waters into Waterford
Harbour. The Suir forms the boundary of the county with Waterford,
and is navigable for small vessels to Carrick. The Nore, which is
navigable to Innistioge, enters the county at its north-western
boundary, and flows by Kilkenny to the Barrow, 9 m. above Ross,
having received the King’s River at Jerpoint and the Argula near
Innistioge. The Barrow, which is navigable beyond the limits of
Kilkenny into Kildare, forms the eastern boundary of the county from
near New Bridge. There are no lakes of any extent, but turloughs or
temporary lakes are occasionally formed by the bursting up of
underground streams.
The coal of the Castlecomer basin is anthracite, and the most
productive portions of the bed are in the centre of the basin at
Castlecomer. Hematitic iron of a rich quality is found in the Cambro-
Silurian rocks at several places; and tradition asserts that silver
shields were made about 850 b.c. at Argetros or Silverwood on the
Nore. Manganese is obtained in some of the limestone quarries, and
also near the Barrow. Marl is abundant in various districts. Pipeclay
and potter’s clay are found, and also yellow ochre. Copper occurs
near Knocktopher.
The high synclinal coal-field forms the most important feature
of the north of the county. A prolongation of the field runs out
south-west by Tullaroan. The lower ground is occupied by
Carboniferous limestone. The Old Red Sandstone, with a Silurian
core, forms the high ridge of Slievenaman in the south; and its

upper laminated beds contain Archanodon, the earliest known
freshwater mollusc, and plant-remains, at Kiltorcan near
Ballyhale. The Leinster granite appears mainly as inliers in the
Silurian of the south-east. The Carboniferous sandstones furnish
the hard pavement-slabs sold as “Carlow flags.” The black
limestone with white shells in it at Kilkenny is quarried as an
ornamental marble. Good slates are quarried at Kilmoganny, in
the Silurian inlier on the Slievenaman range.
On account of the slope of the country, and the nature of the soil,
the surface occupied by bog or wet land is very small, and the air is
dry and healthy. So temperate is it in winter that the myrtle and
arbutus grow in the open air. There is less rain than at Dublin, and
vegetation is earlier than in the adjacent counties. Along the banks
of the Suir, Nore and Barrow a very rich soil has been formed by
alluvial deposits. Above the Coal-measures in the northern part of
the county there is a moorland tract devoted chiefly to pasturage.
The soil above the limestone is for the most part a deep and rich
loam admirably adapted for the growth of wheat. The heath-covered
hills afford honey with a flavour of peculiar excellence.
Proportionately to its area, Kilkenny has an exceptionally large
cultivable area. The proportion of tillage to pasturage is roughly as 1
to 2¼. Oats, barley, turnips and potatoes are all grown; the
cultivation of wheat has very largely lapsed. Cattle, sheep, pigs and
poultry are extensively reared, the Kerry cattle being in considerable
request.
The linen manufacture introduced into the county in the 17th
century by the duke of Ormonde to supersede the woollen
manufacture gradually became extinct, and the woollen manufacture
now carried on is also very small. There are, however, breweries,

distilleries, tanneries and flour-mills, as well as marble polishing
works. The county is traversed from N. to S. by the Maryborough,
Kilkenny and Waterford branch of the Great Southern & Western
railway, with a connexion from Kilkenny to Bagenalstown on the
Kildare and Carlow line; and the Waterford and Limerick line of the
same company runs for a short distance through the southern part
of the county.
The population (87,496 in 1891; 79,159 in 1901) includes about
94% of Roman Catholics. The decrease of population is a little above
the average, though emigration is distinctly below it. The chief towns
and villages are Kilkenny (q.v.), Callan (1840), Castlecomer,
Thomastown and Graigue. The county comprises 10 baronies and
contains 134 civil parishes. The county includes the parliamentary
borough of Kilkenny, and is divided into north and south
parliamentary divisions, each returning one member. Kilkenny
returned 16 members to the Irish parliament, two representing the
county. Assizes are held at Kilkenny, and quarter sessions at
Kilkenny, Pilltown, Urlingford, Castlecomer, Callan, Grace’s Old Castle
and Thomastown. The county is in the Protestant diocese of Ossory
and the Roman Catholic dioceses of Ossory and Kildare and Leighlin.
Kilkenny is one of the counties generally considered to have been
created by King John. It had previously formed part of the kingdom
of Ossory, and was one of the liberties granted to the heiresses of
Strongbow with palatinate rights. Circular groups of stones of very
ancient origin are on the summits of Slieve Grian and the hill of
Cloghmanta. There are a large number of cromlechs as well as raths
(or encampments) in various parts of the county. Besides numerous
forts and mounds there are five round towers, one adjoining the
Protestant cathedral of Kilkenny, and others at Tulloherin, Kilree,

Fertagh and Aghaviller. All, except that at Aghaviller, are nearly
perfect. There are remains of a Cistercian monastery at Jerpoint,
said to have been founded by Dunnough, King of Ossory, and of
another belonging to the same order at Graigue, founded by the earl
of Pembroke in 1212. The Dominicans had an abbey at Rosbercon
founded in 1267, and another at Thomastown, of which there are
some remains. The Carmelites had a monastery at Knocktopher.
There were an Augustinian monastery at Inistioge, and priories at
Callan and Kells, of all of which there are remains. There are also
ruins of several old castles, such as those of Callan, Legan, Grenan
and Clonamery, besides the ancient portions of Kilkenny Castle.
KILKENNY, a city and municipal and parliamentary borough
(returning one member), the capital of county Kilkenny, Ireland,
finely situated on the Nore, and on the Great Southern and Western
railway, 81 m. S.W. of Dublin. Pop. (1901), 10,609. It consists of
Englishtown (or Kilkenny proper) and Irishtown, which are separated
by a small rivulet, but although Irishtown retains its name, it is now
included in the borough of Kilkenny. The city is irregularly built,
possesses several spacious streets with many good houses, while its
beautiful environs and imposing ancient buildings give it an unusual
interest and picturesque appearance. The Nore is crossed by two
handsome bridges. The cathedral of St Canice, from whom the town
takes its name, dates in its present form from about 1255. The see

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Dental Update Volume 47 No 4 April 2020 1st edition ISSN 0305-5000 2515-589X