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Pickard’s Manual of
Operative Dentistry,
Eighth edition
Edwina A. M. Kidd, et al
OXFORD
UNIVERSITY PRESS
OXFORD MEDICAL PUBLICATIONS
Pickard’s Manual of
Operative Dentistry
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Professor HM Pickard 1909–2002
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Edwina A. M. Kidd
Professor of Cariology
Guy’s, King’s, and St Thomas’ Dental Institute
King’s College
London
Bernard G. N. Smith
Professor of Conservative Dentistry
Guy’s, King’s, and St Thomas’ Dental Institute
King’s College
London
Timothy F. Watson
Professor of Microscopy in Relation to Restorative Dentistry
Guy’s, King’s, and St Thomas’ Dental Institute
King’s College
London
Based on the first five editions of A manual of operative dentistry
H. M. Pickard
Emeritus Professor in Conservative Dentistry
University of London
Formerly of the Royal Dental Hospital of London School of Dental Surgery
Pickard’s Manual of
Operative Dentistry
Eighth edition
1
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3
Great Clarendon Street, Oxford OX2 6DP
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© Oxford University Press, 2003
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Database right Oxford University Press (maker)
First edition published 1961
Sixth edition published 1990
Seventh edition published 1996 (reprinted 1996, 1998 (twice), 2000)
Eighth edition published 2003
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stored in a retrieval system, or transmitted, in any form or by any means,
without the prior permission in writing of Oxford University Press,
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British Library Cataloguing in Publication Data
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ISBN 0 19 850928 6
10987654321
Typeset by EXPO Holdings, Malaysia
Printed in China
on acid-free paper by
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It is 41 years since the first edition of this book was pub-
lished. In that time there have been so many developments in
our understanding of dental disease, in materials, and in
techniques so that there is now very little of that first edition
remaining except the basic philosophy for managing
patients with dental disease. This philosophy has several
parallel threads which weave together.
• Dentists primarily look after people with dental prob-
lems – not just mouths or teeth.
• An understanding of the disease processes is funda-
mental to their management.
• The diseases should be managed – not just treated.
• Prevention is the keystone of management. The effect-
iveness of the prevention of dental caries in a selected
group is shown by the fact that about three-quarters of
undergraduate dental students at our dental institute
now have no caries or restorations. Sadly, this is not yet
the case with all people of that generation.
• When treatment is needed, the development of excel-
lent operative skills is still of paramount importance.
This can only be achieved by extensive supervised
clinical practice and chairside teaching which remain
as important as ever in the crowded undergraduate
curriculum. If students do not develop sufficient skill
during their undergraduate course there is little
opportunity for most dentists to develop basic skills in
a supervised setting after qualification.
• When active treatment is needed, the choice of mater-
ials and techniques should be based on a thorough
understanding of them and the advantages and dis-
advantages of the alternatives. This choice is getting
more difficult as the range of materials and techniques
increases so that an even greater understanding of the
properties of dental materials is now necessary.
One of the major developments since the seventh edition
has been the increased use of bonding techniques which in
turn allow much less destructive tooth preparation. For
example, in the seventh edition the use of amalgam for the
management of smooth surface lesions was deleted, and we
now feel that the evidence to support the use of composite
materials for occlusal lesions is sufficient for us to recom-
mend that amalgam should no longer be used for occlusal
restorations. These developments justify a new chapter
(Chapter 6) which brings together parts of other chapters
from the last edition and adds substantial new material.
The intention is that this book contains the material a
student needs to know (except endodontic and periodontal
treatment) up to the point that crowns become necessary. In
other words, students can provide long-term stabilization,
including permanent intracoronal restorations and cores for
crowns, until they have learnt about crowns and then can
continue treating the same patients if that is the policy of their
undergraduate school. An increasing number of schools adopt
policies of ‘whole patient care’ and ‘continuity of care’ so that
students can manage their own patients and all their dental
needs from an early introduction through to the end of the
undergraduate course. In some schools this gives the students
three or more years of contact with some patients at regular
recalls after the initial course of treatment. During that time
they can move on to other procedures, as necessary, with the
same patient, for example crowns, bridges, and partial
dentures. They also have an opportunity to see the short-term
(one or two years) success or failure of their restorations.
Previous editions have included a brief list of ‘further
reading’ at the end of each chapter. This has been brought
up to date and retained but we suggest that readers use the
list of topics at the beginning of each chapter as ‘keywords’
to initiate their own computer search of the literature.
There are two significant, current educational and clinical
concepts which we believe we have developed further in this
edition. The first is ‘problem solving’ and the emphasis on
managing disease rather than treating it as an example of real
problem solving. The second concept is ‘evidence-based prac-
tice’. This is a manual of operative dentistry, not an authori-
tative textbook, however many of the changes in this edition
are based on recent research evidence. If evidence is consid-
ered as not just research-based scientific evidence but
includes the evidence of experience, then we believe that this
edition reflects the current state of play in operative dentistry.
We are considerably indebted to many colleagues who
have allowed us to use their illustrations. They are acknow-
ledged in the captions to the relevant figures together with a
source of the original publication where applicable.
E. A. M. K.
B. G. N. S.
T. F. W.
March 2003
Preface to the eighth edition
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PART I DISEASES, DISORDERS, DIAGNOSIS,
DECISIONS, AND DESIGN
1 Why restore teeth? 5
Dental caries 5
The carious process and the carious lesion 6
Plaque retention and susceptible sites 6
Severity or rapidity of attack 7
The carious process in enamel 7
The carious process in dentine 9
Root caries 11
Secondary or recurrent caries 11
Residual caries 12
Diagnosis of dental caries 12
The diagnostic procedure 12
Assessment of caries risk 16
Symptoms of caries 18
The relevance of the diagnostic information to the
management of caries 18
Preventive, non-operative treatment 18
Patient involvement 19
Why is the patient a caries risk? 19
Mechanical plaque control 19
Use of fluoride 20
Dietary advice 20
Salivary flow 20
Operative treatment 20
Caries in pits and fissures 20
Approximal lesions 20
Smooth surfaces and root caries 20
Tooth wear 20
Erosion 22
Attrition 23
Abrasion 24
Summary of the causes of tooth wear 24
Acceptable and pathological levels of tooth wear 24
Consequences of pathological tooth wear 24
Diagnosing and monitoring tooth wear 24
Preventing tooth wear 27
The management of tooth wear 27
Contents
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Contents
Trauma 27
Aetiology of trauma 27
Examination and diagnosis of dental injury 28
Management of trauma to the teeth 28
Developmental defects 28
Acquired developmental conditions 28
Treatment of developmental defects 30
Hereditary conditions 30
Further reading 31
2 Making clinical decisions 35
Who makes the decisions? 35
Professionalism 35
Large and small decisions 36
The four main decisions 36
Diagnosis 36
Prognosis 36
Treatment options 36
Further preventive measures 34
The information needed to make decisions and how it is collected
and recorded 36
History 37
Examination 40
Examination of specific areas of the mouth 41
Detailed charts 42
Special tests 43
The history and examination process 45
Planning the treatment 46
Some common decisions which have to be made 47
Diagnosing toothache 47
Whether to restore or attempt to arrest a moderate-size carious
lesion and whether to restore or monitor an erosive lesion 50
Whether to extract or root treat a tooth 52
Which restorative material to use 52
Further reading 52
3 Principles of cavity design and preparation 55
G. V. Black 55
Why restore teeth? 55
What determines cavity design? 55
The dental tissues 55
The diseases 56
The properties of restorative materials 56
Resin composites 57
Composition of composites 58
Polymerization of composites 58
Glass ionomer cements 58
Conventional, autocuring, glass ionomer cements 59
Resin-modified glass ionomer cements (RMGIC) 59
Polyacid-modified resin composites (PAMRC) 59
Fluoride-releasing materials 59
Dental amalgam 60
Composition of amalgam alloys and their relevance to clinical
practice 60
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The safety aspects of amalgam 61
Cast gold and other alloys 61
Principles of cavity design 62
When is a restoration needed? 62
Gaining access to the caries 62
Removing the caries 63
How should soft, infected dentine be removed? 63
Stepwise excavation 64
Put the instruments down: look, think, and design 64
The final choice of restorative material 64
Making the restoration retentive 64
Design features to protect the remaining tooth tissue 65
Design features to optimize the strength of the restoration 65
‘Resistance form’ 66
The shape and position of the cavity margin 66
Possible future developments in cavity design 66
The control of pain and trauma in operative dentistry 66
Pre-operative precautions 67
Pain and trauma control during tooth preparation 67
Avoiding postoperative pain 68
Cavity lining and chemical preparation 68
Objectives and materials 68
Further reading 69
PART II TREATMENT TECHNIQUES
4 The operator and the environment 75
The dental team 75
The dental school and practice environment 75
The surgery 76
Positioning the patient, the dentist, and the dental nurse 76
Lighting 77
Siting of work-surfaces and instruments 77
Aspirating equipment; cavity washing and drying 78
Hand and instrument cleaning 78
Close-support dentistry 78
Maintaining a clear working field for the dentist 78
Instrument transfer 79
Moisture control 80
Reasons for moisture control 80
Techniques for moisture control 80
Magnification 86
Protection, safety, and management of minor emergencies 88
Eye protection 88
Airway protection 88
Soft tissue protection 89
Avoiding surgical emphysema 89
Dealing with accidents and accident reporting 90
Protection from infection 90
Further reading 90
5 Instruments and handpieces 93
Hand instruments 93
Instruments used for examining the mouth and teeth 93
ix
Contents
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Contents
Instruments used for removing caries and cutting teeth 94
Instruments used for placing and condensing restorative
materials 94
Hand instrument design 95
Using hand instruments 96
Maintaining hand instruments 96
Sharpening hand instruments 96
Decontaminating and sterilizing hand instruments 97
Rotary instruments 97
The air turbine 97
Low-speed handpieces 97
Maintaining and sterilizing handpieces 98
Burs and stones 98
Finishing instruments 99
Maintaining and sterilizing burs and stones 101
Tooth preparation with rotary instruments 101
Speed, torque, and ‘feel’ 101
Heat generation and dissipation 101
Effects on the patient 101
Choosing the bur for the job 102
Surface finish 102
Finishing and polishing restorations 102
Air abrasion 103
Auxiliary instruments and equipment 103
6 Bonding to tooth structure 107
Why bond to tooth tissue? 107
The substrate; enamel and dentine 107
Enamel 107
Dentine 108
Enamel–dentine junction 108
Cutting 109
Choice of materials for bonding techniques 109
Spectrum of bonding materials 109
Overall requirements for adhesion 109
Composites 110
Bonding to enamel 110
Bonding to dentine 110
Bonding to wet dentine (and enamel) 112
Important considerations on the use of bonding agents 113
Number of stages and film thickness 113
Speed of application 113
Good clear instructions 114
Ease of dispensing and handling 114
Sensitization 114
Shelf-life 114
Glass ionomer cements 114
Adhesion mechanisms: conventional glass ionomer
cements 114
Conditioning the dentine 115
Bonding glass ionomer cements to enamel 115
Bonding glass ionomer cements to dentine 116
The resin-modified glass ionomer cements 116
The polyacid-modified resin composites 117
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[...]... susceptible sites • Severity or rapidity of attack • The carious process in enamel • The carious process in dentine • Root caries • Secondary or recurrent caries • Residual caries Diagnosis of dental caries • The diagnostic procedure • Assessment of caries risk • Symptoms of caries • The relevance of the diagnostic information to the management of caries Preventive, non -operative treatment • Patient involvement... lesions (a) (b) Fig 1.16 (a) A molar tooth with a white spot lesion formed in an area of plaque stagnation at the fissure entrance (b) A hemisection of this tooth showing a larger lesion than would be expected from examination of the outer enamel surface This is purely a function of the direction of the enamel prisms in this region (By courtesy of Dental Update.) Histologically, the carious process may... disorganized or even non-existent Regular removal of the biofilm from the surface of any lesion encourages lesion arrest and these defense reactions then predominate This retreat of the pulp from injury has important implications in the operative management of caries (see p 64) Inflammation is the fundamental response of all vascular connective tissues to injury Inflammation of the pulp (pulpitis) may, as in any... to the offending tooth, and the patient may only be able to indicate which quadrant, or even which side, of the mouth is involved (See Chapter 2 for further details on the diagnosis and management of toothache.) The relevance of the diagnostic information to the management of caries There are three approaches to the management of active caries: • attempt to arrest the disease by preventive, nonoperative... tissues (operative dentistry) and prevent recurrence by preventive, nonoperative treatment • extract the tooth Preventive, non -operative treatment The management of active caries always requires preventive treatment and in cases where cavities preclude plaque control, MOD8E_01(1-32) 11/11/03 11:49 AM Page 19 Preventive, non -operative treatment operative treatment is also needed Notice the use of the... • Mechanical plaque control • Use of fluoride • Dietary advice • Salivary flow MOD8E_01(1-32) 11/11/03 11:49 AM Page 4 Operative treatment • Caries in pits and fissures • Approximal lesions • Smooth surfaces and root caries Tooth wear • Erosion • Attrition • Abrasion • Summary of the causes of tooth wear • Acceptable and pathological levels of tooth wear • Consequences of pathological tooth wear • Diagnosing... there are often areas of tubular sclerosis and reactionary dentine Bacteria seem to penetrate the tissues at an earlier stage in root caries than in coronal caries, although lesions are often rather superficial Despite the presence of these bacteria, active, soft root carious lesions can be converted into arrested lesions by regular tooth brushing with a fluoride-containing dentifrice The soft surface... place Operative dentistry also enables the patient to resume effective plaque control by filling the hole where plaque may stagnate Residual caries When preparing a carious tooth to receive a restoration the dentist removes soft, infected dentine This is part of the carious lesion, but not all of it Demineralization of dentine precedes bacterial infection and beyond the demineralized area is the region of. .. immediately after the patient has seen the hygienist The three-in-one syringe is invaluable in the diagnosis of the depth of penetration of the white spot lesion A white spot lesion that is visible only once the enamel has been throughly dried has penetrated about halfway through the enamel A white or brown spot lesion that is visible on a wet tooth surface has penetrated all the way through the enamel and... would be cavitated (a) (b) (c) (d) Fig 1.28 The radiographs record the progress of approximal caries on the distal aspect of a mandibular first premolar over a period of 18 months in a patient aged 15–16 years This picture has some historical interest It appears in the first edition of this book, published in 1961 Speed of progression is rapid There was no fluoride in toothpaste at this time (a) Early . Pickard’s Manual of Operative Dentistry, Eighth edition Edwina A. M. Kidd, et al OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Pickard’s Manual of Operative Dentistry MOD8E-PRE(i-xiv). first five editions of A manual of operative dentistry H. M. Pickard Emeritus Professor in Conservative Dentistry University of London Formerly of the Royal Dental Hospital of London School of Dental. Surgery Pickard’s Manual of Operative Dentistry Eighth edition 1 MOD8E-PRE(i-xiv) 11/11/03 11:56 AM Page iii 3 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the
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