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CHURCHILL’S POCKETBOOKS

Clinical Dentistry
4th EDITION

Edited by
Professor Crispian Scully CBE
MD, PhD, MDS, MRCS, BSc, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE,
FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed (HC), Dr.hc

Co-Director, WHO Collaborating Centre for Oral Health-General Health;

Emeritus Professor, UCL (London) and Visiting Professor, Universities
of Athens, Edinburgh, Helsinki, Hertfordshire, Middlesex and Plymouth

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2016
© 2016 Elsevier Ltd. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher’s permissions policies
and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).

First edition 1998

Second edition 2002
Third edition 2007
Fourth edition 2016

ISBN 978-0-7020-5150-0
International ISBN 978-0-7020-5149-4

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they have
a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.

Content Strategist: Alison Taylor The

Content Development Specialist: Lynn Watt publisher’s
Project Manager: Julie Taylor policy is to use
Designer: Miles Hitchen paper manufactured
Illustration Manager: Emily Costantino
from sustainable forests
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
 Preface to the
Fourth Edition

As initiators of Clinical Dentistry, and editors of the first three edi-

tions, we are not only pleased to note the impressive success of the book
internationally but, in our increasingly busy senior academic roles, are also
delighted to pass the reins to our long-time colleague and friend, Professor
Crispian Scully CBE, and wish him and the contributors continued success
with the 4th edition.
Professor Ivor Chestnutt Cardiff
Professor John Gibson Glasgow

The primary objective of this Pocketbook was to provide a readily

accessible source of information when it is most needed, as an aide-
mémoire prior to carrying out clinical tasks or to enable students
(at undergraduate and postgraduate level) to apprise themselves
of important details prior to tutorials and seminars. Those aims
remain.
In a publication of this nature, information must be presented in
a concise and, at times, didactic fashion. The intent is to include
sufficient basic information to permit examinations to be passed.
However, the desire of an educationalist is always to promote deep
learning and the layout and content of the text are intended to moti-
vate and guide the reader to the appropriate parts of more substan-
tive texts, many of which have proven both inspirational and
motivational for the editors and contributors of this book throughout
their careers.
This textbook is widely used by more and more undergraduate
dental students, vocational dental practitioners, general professional
trainees, dental surgeons in primary care and in the hospital service,
as well as dental care professionals in-training and post-qualification.
I was requested to take on the editing of the 4th edition. For this
edition I have expanded the size and type of authorship. Although a
large proportion of current contributors were involved in earlier
editions, some previous authors were unavailable to help, so we have
also recruited a range of other top people in their fields. The current
authors are all experienced clinicians, teachers and/or managers
within their individual specialties and emphasis has been given to
information of practical clinical significance. Descriptions of rarely
encountered conditions and situations have been deliberately
minimized.
vi • Preface to the Fourth Edition

In updating this edition, each author has addressed significant

changes within his or her areas of expertise and I am grateful to them
for their enthusiasm and great industry and particularly for comply-
ing with deadlines.
Thus this new 4th edition has not only been invigorated and
enhanced but also the chapter order has been rearranged. We have
also expanded on practical aspects related to the regulator – the
General Dental Council; and on the dental team roles, and practice
management. The book has been written to be used in conjunction
with Scully’s Handbook of Medical Problems in Dentistry (Elsevier
2016) and now includes issues related to overseas dental staff, access
for disabled, advertising, aetiopathogenesis of dental disease, assaults
on staff, behaviour at work and outside (GDC standards), building
design, chaperoning, clothing, finance management, foundation and
vocational training, governance, health and safety, hiring and firing,
identifying staff, independent practice, infection control, information
technology, management skills, marketing, NHS regulations, over-
seas staff, professionalism, protected characteristics, significant event
analysis, time-keeping and things staff must do before starting work
and leaving a job. The aims and objectives remain the same – to
educate and inspire each member of the whole dental team, whether
in-training or post-qualification.
I am indebted for support from the authors, Professor Ivor Chest-
nutt, Professor John Gibson, Professor Justin Stebbing and at Elsevier,
Mrs Lynn Watt and Mrs Alison Taylor. Our thanks are also due to
former contributors, including Iain. B. Buchanan, Barbara. L. Chad-
wick, Ivor. G. Chestnutt, John Gibson, Jason Leitch, Joe McManners,
Jeremy Rees and Dave Stenhouse.
Crispian Scully
London, 2016
 Contributors

Stephen Barter
BDS MSurgDent RCS
Specialist Oral Surgeon
Perlan Specialist Dental Centre
Hartfield Road
Eastbourne, UK

Stephen Barter is Clinical Director of Perlan Specialist Dental Centre, East-

bourne; Specialist in Oral Surgery and Hon. Lecturer in the Department of
Periodontology, UCL Eastman Dental Institute, London; ITI Fellow and past
Chairman of the UK and Ireland ITI Section and has been involved in the teach-
ing and development of dental implantology for over 20 years.

John A.D. Cameron

BDS DGDP LLB (Hons)
Senior Clinical/Dental Adviser
Practitioner Services
NHS National Services Scotland
Edinburgh;
University of Aberdeen Dental School
Aberdeen, UK

John Cameron is Senior Dental Adviser at NHS National Services Scotland,

Senior Clinical Lecturer at the University of Aberdeen Dental School, Lead for
Law, Ethics and Professionalism. He is also Chairman of the Dentists Health
Support Programme and Trust.
viii • Contributors

Iain Chapple
BDS FDSRCPS PhD FDSRCS CCST (Rest Dent)
Periodontal Research Group and MRC Centre for
Immune Regulation
School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Professor Iain Chapple is Head of Periodontology at the University Birming-

ham’s School of Dentistry and Clinical Lead for an NHS service base of 6
million. He is Associate Editor of Journal of Clinical Periodontology and Period-
ontology 2000 and former Scientific Editor of the British Dental Journal and
former Associate Editor of Journal of Periodontal Research. President of The
British Society of Periodontology (2014–2015), President of The Periodontal
Research Group of the International Association of Dental Research (2007),
Treasurer and Executive Committee member of the European Federation of
Periodontology (EFP) (2007–2013), EFP Scientific Advisory Committee Chair-
man (2013–2015), Secretary General (2016–), EFP Workshop Co-Chairman
(2009–current). He has written and edited seven books and 16 book chapters
and published over 140 full papers on Medline. He was awarded the Tomes
Medal by the Royal College of Surgeons of England in 2012.

Fiona Cox
B.Ed MInstLM
Ferndale Dental Clinic Ltd
Devizes, UK

Fiona Cox is co-owner at Ferndale Dental Implant and Cosmetic Clinic. She has
a wide experience in management within the private health sector and the NHS
dental and medical health fields.
 Contributors • ix

Martyn Cox
BSc (Hons) BDS MFGDP RCS (Eng) FRSM, PhD
Clinical Director Ferndale Dental Implant Clinic
Implant mentor and tutor Dentale Advanced
Implant course, Honorary Specialist Oral Surgeon,
Solihull Hospital
Lecturer

Martyn Cox is the Clinical Director at Ferndale Dental Implant and Cosmetic
Clinic, Devizes. He is a clinical trainer/lecturer and mentor in Advanced
Implantology in Bristol and Shrewsbury, an Honorary Oral Surgeon at Solihull
Hospital, Birmingham and a lecturer on the FGDP Oral Surgery course. Martyn
has been awarded numerous research prizes in the UK and has published
widely in both UK and international peer-reviewed journals including several
oral cancer textbooks and has lectured on implantology, oral cancer and
human papilloma virus genetics in the UK, Europe and the USA.

Daljit Gill
BDS BSc MSc FDS RCS MOrth FDS (Orth) RCS (Eng)
UCLH Eastman Dental Hospital
London, UK

Dr Daljit Gill is a Consultant Orthodontist at Great Ormond Street NHS Founda-

tion Trust and UCLH Eastman Dental Hospital. He has written a number of
textbooks and is involved in training orthodontists, therapists and nurses.
x • Contributors

Nikos Donos
DDS MS FHEA FDSRCSEngl PhD
Head Centre for Oral Clinical Research
Professor and Chair Periodontology and Implant Dentistry
Honorary Professor, UCL Eastman Dental Institute, UK
Honorary Professor, University of Hong Kong
Honorary Professor, Griffith University, Australia
Centre for Clinical Oral Research
Institute of DentistryBarts and The London School of
Medicine and DentistryQueen Mary University of
London (QMUL)

Awarded the title of Honorary Professor at the Faculty of Dentistry in Hong

Kong (2009) and the title of Adjunct Professor at the Dental School, Griffith
University, Australia (2012), Professor Donos is involved as editorial board
member in a number of international and national peer-reviewed journals in
the field of Periodontology and Implant Dentistry and has published exten-
sively. In 2011, he was awarded the prestigious annual IADR-Periodontology
Group Award in Periodontal Regenerative Medicine. His clinical expertise is in
the field of Periodontics and Implant Dentistry and he has significant experi-
ence in periodontal/bone regeneration and implant related surgical procedures
as well as treatment of peri-implantitis, topics which he regularly lectures on
at a national and international level.

David H. Felix
BDS MB ChB FDS RCS (Eng) FDS RCPS (Glasg) FDS
RCS(Ed) FRCP(Ed)
Dean of Postgraduate Dental Education
NHS Education for Scotland
Edinburgh, UK

Dr David H. Felix is Postgraduate Dental Dean, NHS Education for Scotland and
Chair of the Joint Committee for Postgraduate Training in Dentistry. Previously
Consultant in Oral Medicine Glasgow Dental Hospital and School. He is a
former Dean of the Faculty of Dental Surgery of The Royal College of Surgeons
of Edinburgh and a former President of the British Society for Oral Medicine.

Mark Griffiths
MBBS FDS RCS BDS
Visiting Professor, UCL (Eastman Dental Institute);
Honorary Research Fellow, School of Physiology,
Pharmacology and Neuroscience
University of Bristol
Bristol, UK

Mark Griffiths is Visiting Professor, UCL (Eastman Dental Institute), London,

UK and Honorary Research Fellow, School of Physiology, Pharmacology and
Neuroscience at the University of Bristol. He is a retired NHS Consultant in
Special Care Dentistry at the Bristol Dental Hospital. Holder of Patent: Monitor-
ing electrical activity (Electroencephalograph) and Member of University of
Bristol Neuroscience Community.
 Contributors • xi

Athanasios Kalantzis
DipDS MFDSRCS MBChB MRCS FRCS (OMF)
Oral and Maxillofacial Surgery Consultant
Central Manchester Foundation Trust
Manchester, UK

After qualifying in Dentistry in Athens, Greece and in Medicine in Sheffield,

UK, Mr Kalantzis trained in Oral and Maxillofacial Surgery at the Oxford Uni-
versity Hospitals and served as Members Representative and Fellows in Train-
ing Representative of the British Association of Oral & Maxillofacial Surgeons
as well as Officer of the Junior Trainees Group. He is a member of the Royal
College of Surgeons of England and has taught oral and maxillofacial trainees
for several years. He has presented papers nationally and internationally and
has experience in organizing as well as chairing national and international
conferences.
Mr Kalantzis is co-author of the books Oxford Handbook of Dental Patient Care
2e and the Oxford Specialist Handbook of Medicine and Surgery for Dentists and is
on the Editorial Board of Medical Problems in Dentistry 6e, and is a regular
reviewer for journals such as Oral Oncology and British Journal of Oral & Maxil-
lofacial Surgery.

Tatiana Macfarlane
BSc PhD MICR FHEA
Senior Research Fellow
University of Aberdeen, Dental School
Aberdeen, UK

Dr Tatiana Macfarlane is a Senior Research Fellow at the University of Aber-

deen Dental School, UK. She previously worked at the University of Manchester
in England, European Institute of Oncology in Italy and International Agency
for Research of Cancer in France. Her main research interests are in epidemiol-
ogy of head and neck cancer and oral health epidemiology. She has been
involved in major international collaborations such as Alcohol-related Cancers
and Genetic Susceptibility in Europe (ARCAGE) and International Head and
Neck Cancer Epidemiology Consortium (INHANCE). She is a Fellow of the
Royal Statistical Society (RSS), Fellow of the Institute of Learning and Teaching
in Higher Education (ILTHE), member of the International Epidemiological
Association (IEA), member of the American Association for Cancer Research
(AACR) and professional member of the Institute of Clinical Research (ICR).
She has authored over 120 peer-reviewed papers.
xii • Contributors

Avril Macpherson
BDS (Edin) FDS RCSEd MFDS RCSEd MSND RCSEd
DipConSed (N’castle) PGCTLCP (Edgehill) FHEA
Clinical Director
Liverpool University, Dental Hospital
Liverpool, UK

Avril Macpherson was appointed Consultant/Honorary Senior Clinical Lec-

turer in Special Care Dentistry, Liverpool University Dental Hospital and School
of Dentistry, in 2010. She is a member of the British Society of Disability and
Oral Health Executive Committee, the Specialty Advisory Committee in Special
Care Dentistry (RCSEng), the Specialty Advisory Board in Oral Medicine and
Special Care Dentistry (RCSEd) and is a Regional Specialty Advisor in Special
Care Dentistry (RCSEng). Avril teaches widely in conscious sedation and special
care dentistry and is a member of teaching faculty of the Society for the
Advancement of Anaesthesia in Dentistry and a Resuscitation Council
Advanced Life Support instructor. She is a RCSEd examiner for MFDS and
MSCD examinations.

Jasmine Murphy
BDS (Hons) MSt (Camb) MFGDP UK MFDS RCS (Edin)
MFDS RCS (Eng) MRes (Manc) FDS RCS (Eng) FFPH
Consultant in Public Health (Children and Young
People, Sexual Health, Dental Public Health)
Leicester City Council
Leicester, UK

Jasmine Murphy is a Consultant in Public Health at Leicester City Council and

registered as a Specialist in Dental Public Health with the General Dental
Council. Children in Leicester have been reported to have the worst level of
dental health in England and therefore Jasmine established the Oral Health
Promotion Partnership Board and is driving forward the implementation and
mobilization of Leicester’s first Oral Health Promotion Strategy for pre-school
children. Leicester’s dental public health programme ‘Healthy Teeth, Happy
Smiles!’ is an early intervention programme that is modelled on Scotland’s
ChildSmile. Jasmine also contributed to Public Health England’s ‘Commission-
ing Better Oral Health’ guidance, is a core member of the National Institute
of Health and Care Excellence (NICE) Public Health Advisory Committee
and is also currently contributing to NHS England’s Commissioning Guide on
Paediatric Dentistry. Jasmine has also recently been invited to join the Editorial
Board of Oral Diseases journal.
 Contributors • xiii

Farhad B. Naini
BDS (Guy’s) MSc (Lond) PhD (KCL) FDSRCS (Eng)
MOrthRCS (Eng) FDSOrth.RCS (Eng) GCAP(KCL) FHEA
Consultant Orthodontist
Maxillofacial Unit
Kingston Hospital and St George’s Hospital
London, UK

Dr Naini is the Consultant Orthodontist in the Maxillofacial Units at Kingston

Hospital and St George’s Hospital, Chair of the multidisciplinary Cranio-Orbito-
Facial Surgery Group and Research Lead for Dentistry and Orthognathic
Surgery. He has over 80 peer-reviewed publications and is editor of major
textbooks on orthodontics and orthognathic surgery. He is also author of the
reference textbook Facial aesthetics: concepts and clinical diagnosis.

Tim Newton
BA PhD CPsychol AFBPsS CSci
Unit of Social and Behavioural Sciences
King’s College London, Dental Institute
Guy’s Hospital
London, UK

Professor of Psychology as Applied to Dentistry and Honorary Consultant

Health Psychologist at King’s College London Dental Institute, Tim has worked
in the behavioural sciences in relation to dentistry for over 20 years, and his
particular interests include the management of dental anxiety, interventions
to enhance oral health related behaviour and the working life of the dental
team. He has published over 250 peer-reviewed articles in scientific journals.

Paul P. Nixon
BDS FDSRCS (Eng) DDRRCR
Consultant in Maxillofacial Radiology
School of Dentistry
Liverpool University, Dental Hospital
Liverpool, UK

Paul Nixon is Consultant in Maxillofacial Radiology in Royal Liverpool Univer-

sity Hospital, clinical lead in the Dental Radiology Department and is also a
specialist in Oral Surgery. He is an honorary clinical lecturer of the University
of Liverpool and has an honorary contract at Alder Hey Children’s Hospital.
He has authored or coauthored 26 publications. He is on the council of the
British Society of Dental and Maxillofacial Radiology where he is audit lead and
is responsible for their website. He recently served as external examiner for the
MSc in Maxillofacial radiology at King’s College London for 6 years, is an
examiner for the MJDF examination of the Royal College of Surgeons of
England and is a member of the Royal College of Radiologists.
xiv • Contributors

Will Palin
BMedSc MPhil PhD FADM
Biomaterials Unit, The School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Will Palin is a Reader in Biomaterials at the School of Dentistry, University of

Birmingham. With a background in materials science, his developmental
research for both dental and wider medical applications has attracted grant
funding from the EPSRC, BBSRC, NIHR, Ministry of Defence and various indus-
trial partners. He has authored over 70 publications and six book chapters. He
is Editor of the European Journal of Prosthodontics and Restorative Dentistry,
Subject Editor for Biomaterials Adhesion, International Journal of Adhesion and
Adhesives and Board Member for Journal of Biomaterials Applications, Dental
Materials and Journal of Dentistry.

Andrew Paterson
LLM BDS (Hons) FDSRCPS DRDRCS (Edin) MRDRCS (Edin)
Consultant in Restorative Dentistry, NHS Ayrshire and
Arran;
Honorary Clinical Senior Lecturer, University of
Glasgow;
Maxillofacial Unit
The University Hospital Crosshouse
Kilmarnock, UK

Andrew Paterson is a Consultant in Restorative Dentistry mainly involved in

the prosthodontic management of head and neck cancer, trauma and hypo-
dontia patients in a District General Hospital. Formerly an NHS Consultant at
Glasgow Dental Hospital with 20 years’ experience in a private specialist restor-
ative and prosthodontics referral practice dealing with all aspects of restorative
dentistry. Part-time associate dento-legal adviser with an indemnity insurer.
Contributor to all previous editions of this textbook.

Crispian Scully
CBE PhD MD MDS MRCS FDSRCPS FFDRCSI FDSRCS
FDSRCSE FRCPath FmedSci FHEA FUCL FSB DSc DChD
DMed (HC) Dr HC
Emeritus Professor
University College London
London, UK

Professor Crispian Scully is a Director of the WHO Collaborating Centre in

Oral Health-General Health; journal Founder and Editor of Oral Oncology and
Oral Diseases; and author or editor of 50 books, 200 book chapters and over
1000 papers on MEDLINE. He is UCL Professor Emeritus, has been Dean at UCL
and Bristol, and president of several international and UK societies and has
medals from Universities of Helsinki, Santiago de Compostela and Granada;
Fellowship of UCL; and Doctorates from Universities of Athens, Granada, Hel-
sinki and Pretoria.
 Contributors • xv

John C. Steele
MB ChB BDS MFDS RCSEd FDS (OM) RCSEd Dip Oral
Med PGCTLCP FHEA
Consultant and Specialist in Oral Medicine
The Leeds Teaching Hospitals NHS Trust;
Honorary Senior Lecturer in Oral Medicine
Faculty of Medicine & Health
University of Leeds
Leeds, UK

Dr John C. Steele is dual qualified in both medicine and dentistry and is cur-
rently Consultant, Honorary Senior Lecturer and Specialist in Oral Medicine
based in Leeds. He has previously worked in a number of medical and surgical
posts including emergency medicine. He has co-authored 14 articles published
in peer-reviewed journals and has reviewed manuscripts for five national and
international dental and medical journals. He is a current member of Council
of the British Society for Oral Medicine.

Damien Walmsley
PhD MSc BDS FDSRCPS
The School of Dentistry
College of Medical and Dental Sciences
University of Birmingham
Birmingham, UK

Professor Walmsley is a recognised both for his research and teaching. His
research is on the the use of ultrasonics in dentistry including its use in period-
ontology, endodontics and its healing effects in repairing teeth. His present
research funding includes imaging biofilm and observing its real time removal
via ultrasonic instruments. He is very active in Interdisciplinary doctoral train-
ing centres at the University of Birmingham and is Graduate Director for
Dentistry. He publishes his work in high impact scientific journals which has
resulted in research and advisory roles for all the major dental companies. He
is a well respected educator in Prosthodontics and also contributes to courses
on Information Technology and Law/ethics courses. Clinically his work evolves
around Prosthodontics and he is the leader of a busy NHS department. He is
Scientific Advisor to the British Dental Association and enjoys a high profile in
the media. He is a past President of the British Prosthodontic Society. Interna-
tional roles include Past President of the Association for Dental Education in
Europe and deputy chair of U21 Health Sciences. Editorial duties include past
Editor of the Journal of Dentistry and he is on the Editorial boards of the BDJ,
European Journal of Dental Education, Journal of Dental Education, Journal
of Endodontics. European Journal of Restorative Dentistry and Dental Update.
xvi • Contributors

Richard Welbury
Professor of Paediatric Dentistry
School of Dentistry
University of Central Lancashire
Preston, UK

Richard Welbury is Professor of Paediatric Dentistry at the University of

Glasgow Dental School and currently Dean of the Dental Faculty and Vice-
President of the Royal College of Physicians and Surgeons of Glasgow.

Paul H.R. Wilson

BSc BDS MSc FDSRCPS FDS(RestDent) DipDSed
Consultant in Restorative Dentistry
Oxford University Hospitals NHS
Foundation Trust, Headington, Oxford UK
The Circus Dental Practice
Bath, UK

Paul H.R. Wilson is Consultant in Restorative Dentistry at Oxford University

Hospitals NHS Foundation Trust and he works in private specialist dental prac-
tice in Bath. He is visiting Senior Clinical Lecturer at the Universities of Aber-
deen and Bristol. He completed postgraduate training at Guy’s & St Thomas’
Hospitals, London and King’s College London.

Graeme Wright
BDS FDS(Paed Dent) RCPSG MPaed Dent RCSEd
PGCLTHE FHEA
Consultant in Paediatric Dentistry
Royal Hospital for Sick Children
Edinburgh, UK

Graeme Wright is Consultant in Paediatric Dentistry at Edinburgh Royal

Hospital for Sick Children. He is an Executive Board member of BSPD, organizer
of the IAPD 2015 International Congress and editorial board member of
‘Dental Traumatology’. His sub-specialty interests are Dental Traumatology
and Oncology/Haematology related to dentistry.
 Contents

Preface to the Fourth Edition v

Contributors vii

1. Dental public health, epidemiology and prevention 1

Tatiana Macfarlane, Jasmine Murphy

2. Social and psychological aspects of dental care 27

Tim Newton

3. Dental disease 39
Crispian Scully

4. The dental team 71

Crispian Scully, John Cameron

5. Law, ethics and quality dental care 93

John Cameron

6. Practice management 121

Fiona Cox, Martyn Cox

7. History and examination 167

Mark Griffiths

8. Dental and maxillofacial radiology 175

Paul Nixon

9. Pain and anxiety management 201

Avril Macpherson

10. Drug prescribing and therapeutics 223

Mark Griffiths

11. Dental materials 237

William Palin, Damien Walmsley
xviii • Contents

12. Implantology 269

Stephen Barter, Nikos Donos

13. Oral medicine 289

David H. Felix

14. Oral and maxillofacial surgery 337

Athanasios Kalantzis

15. Orthodontics 391

Daljit Gill, Farhad Naini

16. Paediatric dentistry 429

Graeme Wright, Richard Welbury

17. Periodontology 461

Iain Chapple

18. Removable prosthodontics 475

Andrew Paterson

19. Operative dentistry 513

Paul H.R. Wilson

20. Special care dentistry 577

Avril Macpherson

21. Emergencies 621

John Steele

Appendices 637
Appendix A: Average dates of mineralization and eruption
of the primary dentition 638
Appendix B: Tooth notation 640
Appendix C: Tooth eruption 640

Index 643
 1
Dental public health,
epidemiology
and prevention
Dental public health 1 Hookah (shisha) and oral health 19
Oral health epidemiology 3 Alcohol consumption and oral
The prevention of oral diseases 4 health 19
The wider determinants of Other substance abuse and oral
health 5 health 21
Oral health promotion 6 HIV infection and oral health 21
Common risk factors 6 Prevention of dental neglect 22
Barriers to healthy behaviours 7 Sport trauma 23
Changing disease levels 8 Temporomandibular disorders 23
Caries risk 9 Frequency of dental attendance 23
Diet and dental caries 10 Routine scale and polish 23
Fluoride 12 Prevention in older patients 24
Modes of action 12 Pregnancy and oral health 25
Smoking and oral health 16 Oral health in special population
Smokeless tobacco and oral groups 25
health 17 Conclusion 26
Electronic cigarettes and oral
health 18

Dental public health

Definition
This is a non-clinical specialty involving the science and art of preventing oral
diseases, promoting oral health to the population rather than the individual.
It involves the assessment of dental health needs, developing policy and
strategy and ensuring appropriate dental health services to meet the needs
of the population.

Dental Public Health (DPH) is concerned with the oral health of a

population rather than individuals and has been defined as the
science and art of preventing oral diseases, promoting oral health
and improving the quality of life through the organized efforts of
society. Dental public health practice requires an understanding of
the challenges in the delivery, planning and management of health
services in order to ensure that the provision of health services meets
the needs of the population. This dental specialty requires specific
skills in undertaking oral health needs assessments and developing
specific oral health policies and strategies that protect and promote
2 • C L I N I C A L D E N T I S T RY

population level oral health. It also involves a comprehensive under-

standing and appreciation of the principles and methods that under-
pin oral health promotion, oral health inequalities, the wider
determinants of health and health behaviour.
Oral health has improved in the UK over the last 30 years, but there
is evidence that inequalities have widened. With limited funding and
the ever-growing evidence base for interventions, dental public
health specialists must make decisions, develop policies and imple-
ment strategies that are based on the best available scientific evidence
in order to meet oral health goals, reduce oral health inequalities and
sustain necessary resources. Such activities also involve the system-
atic use of data and information systems, application of programme
planning frameworks, engagement with the communities in the
decision-making process, conducting sound evaluation and dissemi-
nating lessons that have been learnt.
The evidence-based decision-making process which is applied
in dental public health integrates best available research evidence,
practitioner expertise and other available resources including the
characteristics, needs, values and preferences of those who will
be affected by the intervention. Once health needs are identified
through a community assessment, the scientific literature can iden-
tify programmes and policies that have been effective in addressing
those needs. However, the amount of available evidence can be
overwhelming.
There are many types of evidence (e.g. randomized controlled
trials, cohort studies, qualitative research) and the best type of evi-
dence depends on the question being asked. Not all types of evidence
(e.g. qualitative research) are equally represented in reviews and
guidelines. The concept of a ‘hierarchy of evidence’ can be problem-
atic when appraising the evidence for public health interventions
as not all populations, settings and health issues are necessarily
represented in evidence-based guidelines and/or systematic reviews.
An important objective for those engaged in evidence-based dental
public health is to improve the quality, availability and use of evi-
dence in public health decision-making. The wide-scale implementa-
tion of evidence-based dental public health requires not only a
workforce that understands and can implement the evidence base for
dental public health efficiently but also sustained support from health
department leaders, practitioners and policy makers.
Evidence-based practice guidelines are based on systematic reviews
and/or meta-analyses of research-tested interventions and can help
practitioners select interventions for implementation.

• Systematic reviews use explicit methods that focus on a particular

research question which locates and critically appraises all high
quality research evidence relevant to that question. They result
 Dental public health, epidemiology and prevention • 3

in reports and recommendations that summarize the effectiveness

of particular interventions, treatments or services and often
include information about their applicability, costs and implemen-
tation barriers.
• Meta-analysis is a statistical technique to combine pertinent data
from several studies to develop a single conclusion that has
greater statistical power. The benefits of meta-analysis include a
consolidated and quantitative review of the large, complex and
sometimes conflicting body of literature.

The Cochrane Library (http://www.cochranelibrary.com) is an

online collection of databases that contain different types of high-
quality, independent evidence to inform healthcare decision-making.
The Centre for Evidence-based Dentistry (CEBD; http://www.cebd.org)
sets out an approach to systematizing the evidence for different
research questions, with the highest level of evidence being system-
atic reviews and randomized clinical trials, with case series and
expert opinion as the lowest level of evidence.
To find evidence tailored to their own context, practitioners may
need to search resources that contain original data and analysis.
Peer-reviewed research articles, conference proceedings and techni-
cal reports can be found for example in PubMed (http://www.ncbi
.nlm.nih.gov/pubmed). Maintained by the US National Library of
Medicine, PubMed is the largest and most widely available biblio-
graphic database of biomedical literature.

Oral health epidemiology

Epidemiology, which is defined as the study of disease distribution
and its determinants in specified populations, is the basic science of
public health because it studies the patterns, causes and effects of
health and disease conditions in human populations. It is the corner-
stone of public health and informs policy decisions and evidence-
based practice by identifying risk factors for disease and targets for
preventive health care. Furthermore, epidemiology has been used to
generate much of the information required by public health profes-
sionals to develop, implement and evaluate effective intervention
programmes for the prevention of disease and promotion of health,
such as the eradication of smallpox, the anticipated eradication of
poliomyelitis, and prevention of diphtheria, tetanus, measles, menin-
gitis and mumps, heart disease and cancer. The ‘art’ of epidemiology
is knowing when and how to apply the various epidemiological strat-
egies to answer specific health questions. Such designs include
descriptive epidemiological studies (such as cross-sectional or
surveys) and analytical (such as cohort studies, case-control studies
and randomized clinical trials).
4 • C L I N I C A L D E N T I S T RY

Dental caries is a public health concern and collecting data on its

prevalence, incidence and trends is an important field in oral health
epidemiology. Definitions used include:
• Prevalence: the proportion of individuals with disease (cases) in
a population at a specific point in time.
• Incidence: the number or proportion of individuals in a popula-
tion who experience new disease during a specific time period.
• Trend: the changes or differences in the prevalence or incidence
of disease with respect to time.

The prevention of oral diseases

The major oral diseases – dental caries, periodontal disease and
mouth cancer (see Chapter 3) – are not inevitable, but are to a large
extent influenced by the wider determinants of health, i.e. psychoso-
cial, economic, political, environmental, social and lifestyle factors.
The aetiology of these conditions is increasingly well understood and
prevention is largely possible if appropriate policies and strategies are
in place which influence or assist people in adopting appropriate
changes in behaviour.
Prevention is defined in three stages:

• Primary prevention – steps taken to ensure disease does not occur

• Secondary prevention – promoting early intervention in those already
affected to halt progression at incipient stage of disease
• Tertiary prevention – treatment of well-established disease to restore
function and avoid further episodes

The prevention of oral diseases can also be regarded as measures

applied either on a population basis, or at an individual level. Examples
of measures applied on a population basis include water fluoridation
and health promotion campaigns. Preventive measures on an indi-
vidual basis can be applied either by a dental professional (e.g. fluo-
ride varnish, fissure sealants, diet counselling, smoking cessation) or
by the individual, e.g. tooth-brushing.
In the developed world, dentistry has traditionally taken a
‘treatment-oriented’ approach, with the view that individuals were
reliant on dental professionals for maintenance of oral health, but
recent decades have seen a change to a more ‘preventive-oriented’
approach. Factors influencing this transition include:
• increased understanding of the nature of dental caries, periodon-
tal disease and other oral diseases
• increased appreciation of the shortcomings of traditional restora-
tive dentistry
 Dental public health, epidemiology and prevention • 5

• increased evidence based on preventative approaches

• changing aspirations of patients (perhaps of greatest
importance).

The wider determinants of health

Oral health and general health are determined by a complex interac-
tion between individual characteristics, lifestyle and the physical,
social and economic environment. People living in poorer areas tend
to have worse oral and general health when compared to those living
in more affluent areas. Given the close links between oral health and
other indicators such as family income, there is increasing pressure
to tackle the wider social determinants of health through the imple-
mentation of appropriate interventions. The wider social determi-
nants of health (Figure 1.1) are the circumstances in which people
are born, grow up, live, work, and age. These circumstances are in
turn shaped by a wider set of forces: economics, social policies and
politics.
Oral health inequalities are the ‘differences in oral health status
between different population groups’. Inequalities in oral health exist
between social classes, countries within the United Kingdom and
among certain minority ethnic and population groups. Oral health
inequalities can only be reduced through the implementation of
effective and appropriate oral health promotion policies and strate-
gies which tackle the wider social determinants of health. The

General socioeconomic,
cultural and environmental conditions
Living and working
conditions
Social and
community networks
Individual
lifestyle factors

• Work environment Individuals • Housing

• Unemployment (age, gender and • Water and sanitation
• Education genetic factors) • Agriculture and food
• Healthcare services production

Figure 1.1 Determinants of health (based on Dahlgren G & Whitehead M 1991

Policies and strategies to promote social equity in health. Institute for Future
Studies, Stockholm (Mimeo).
6 • C L I N I C A L D E N T I S T RY

improvements in oral health over the last 30 years have been largely
a result of fluoride toothpaste and social, economic and environmen-
tal factors.

Oral health promotion

Health promotion is the process of enabling people to increase control
over, and to improve their health (World Health Organization
[WHO]). It moves beyond a focus on individual behaviour towards a
wide range of social and environmental interventions. Health pro-
motion describes activities and actions designed to enhance positive
health and prevent ill-health by a combination of prevention, health
education and health protection. There are a number of approaches
that can be chosen when planning an oral health promotion initia-
tive including: settings (e.g. nurseries, schools, care homes), popula-
tion group (e.g. children, pregnant women, adults, vulnerable
groups) and topic based (e.g. dental caries, periodontal disease, oral
cancer).
Prevention. Described above.
Health education. Any combination of learning experiences
designed to help individuals and communities improve their health
by increasing their knowledge or influencing their attitudes (WHO).
It involves the provision of information aimed at influencing beliefs,
attitudes and behaviour relating to oral and dental health. In its
widest sense, it also includes provision of information about access
to and appropriate use of health services.
The key messages for oral health (see Chapter 3) are: reduce the
intake of sugar-containing food and drink, particularly the frequency
of sugar consumption and avoid between-meal sugar snacks; brush
teeth twice daily with a toothpaste containing fluoride; attend the
dentist regularly; do not use tobacco; reduce alcohol consumption.
Health protection. The practice of a nation to protect, improve and
restore health of individuals in a community or entire populations.
It functions through collective societal activities, programmes, serv-
ices and institutions aimed at improving health of people. It com-
prises laws, regulations, policies and voluntary codes of practice
aimed at preventing disease and enhancing health, e.g. legislation
making use of car seat-belts compulsory, thereby reducing the preva-
lence of maxillofacial injuries due to road traffic accidents.

Common risk factors

Traditionally, there has been an emphasis on dental health educa-
tion, either with individuals or groups, which has focused on impart-
ing knowledge. It has been shown that conventional oral health
 Dental public health, epidemiology and prevention • 7

Risk conditions

Risk factors Diseases Risk factors

Diet Obesity Tobacco
Cancers
Stress Heart disease Alcohol
School Workplace
Respiratory disease
Control Dental caries Exercise
Periodontal disease
Policy Hygiene Trauma Injuries Housing

Political Physical Social

environment environment environment
Figure 1.2 Common risk approach. Reproduced from Watt RG, Sheiham S 2000
The common risk factor approach: a rational basis for promoting oral health.
Community Dentistry and Oral Epidemiology 28(6):399–406 with permission
from John Wiley.

education is neither effective nor efficient (Kay and Locker, 1996),

especially if these oral health programmes only concentrate on indi-
vidual behaviour change and do not take into account the influence
of socio-political factors as the key determinants of health.
The common risk factor approach (Figure 1.2) takes a broader
perspective and targets risk factors common to many chronic condi-
tions and their underlying social determinants. The key concept of this
approach is that concerted action against common health risks and
their underlying social determinants will achieve improvements in a
range of chronic health conditions more effectively and efficiently
than isolated, disease-specific approaches. This approach acknowl-
edges that many diseases have common predisposing risk factors to
oral health. A poor diet that is high in sugars, and smoking are
examples of behaviours which impact adversely upon oral as well as
general health. As these causes are common to a number of other
chronic diseases, adopting a collaborative approach is more rational
than one that is disease specific. It also recognizes that engendering
lasting changes in individual ‘lifestyle’ behaviours requires support-
ive social, economic and political environments.

Barriers to healthy behaviours

The principle of health education is that by provision of appropriate
information and circumstances, beliefs and attitudes of individuals
8 • C L I N I C A L D E N T I S T RY

Upstream
Stop! Do not
‘Causes of the
jump in
causes’

General
politics Midstream
Help Help
Social policy

Public health policy + strategy

Health promotion Health care and services

Downstream

Lifestyle
Economy Life chances Health Quality of life
and environment

Figure 1.3 Upstream and downstream approaches.

will be affected sufficiently to result in the adoption of behaviour

likely to enhance health and diminish the chance of disease. However,
dental disease is heavily influenced by socioeconomic and other con-
straints that may restrict the choices available. Whilst parents may
realize that fresh fruit is preferable to chocolate bars, non-availability
or price may preclude its provision. Similarly, sugar-containing food-
stuffs are often given to children not only when they are hungry but
also as a reward or a pacifier.
The dominant preventive approach in dentistry, i.e. narrowly
focusing on changing the behaviours of high-risk individuals, has
failed to effectively reduce oral health inequalities, and indeed may
have increased the oral health equity gap. A conceptual shift is
needed away from this biomedical/behavioural ‘downstream’
approach, to one addressing the ‘upstream’ underlying social deter-
minants of population oral health (Figure 1.3).
Failure to change our preventive approach is a dereliction of
ethical and scientific integrity (Public Health England, 2014).

Changing disease levels

Dental disease levels in the UK population have reduced significantly
in the last three decades.
 Dental public health, epidemiology and prevention • 9

The 2009 Adult Dental Health Survey demonstrated that the pro-
portion of edentulous adults fell dramatically from 30% in 1978 to
6% in 2009. However, the survey also showed that stark inequalities
exist. For example, people from managerial and professional occupa-
tion households had better oral health (91%) compared with people
from routine and manual occupation households (79%) (The Health
and Social Care Information Centre, 2011).
The 2013 National Children’s Dental Health Survey (Office for
National Statistics, 2015) showed that there were reductions in the
extent and severity of tooth decay present in the permanent teeth of
12 and 15 year olds overall in England, Wales and Northern Ireland
between 2003 and 2013.
Large proportions of children, however, continue to be affected by
disease, and the burden of disease is substantial in those children that
have it. In 2013, nearly a half (46 per cent) of 15 year olds and a
third (34 per cent) of 12 year olds had “obvious decay experience” in
their permanent teeth. This was a reduction from 2003, when the
comparable figures were 56 per cent and 43 per cent respectively.
Furthermore, nearly a third (31 per cent) of 5 year olds and nearly
a half (46 per cent) of 8 year olds had obvious decay experience in
their primary teeth. Untreated decay into dentine in primary teeth
was found in 28 per cent of 5 year olds and 39 per cent of 8 year
olds. Overall, 58 per cent of 12 year olds and 45 per cent of 15 year
olds reported that their daily life had been affected by problems with
their teeth and mouth in the past three months.
Caries still affects a large number of children in lower socioeco-
nomic groups and within some ethnic minorities, as do its sequelae
(odontogenic infections; Chapter 3). There is a threefold difference in
levels of caries between the least and most deprived communities.
Upstream action addressing risks, beliefs, behaviours and the living
environment by ensuring appropriate policies and strategies are in
place are probably as important as affordable access to professional
treatment. This follows the sentiment of the Marmot Review ‘Fair
Society, Healthy Lives’, which dominates the wider public health
agenda of tackling avoidable differences in health using an ‘upstream’
approach. An upstream approach is when trying to change people’s
individual behaviours (such as encouraging the use of fluoride tooth-
paste with tooth brushing or adding fluoride to the water supply),
leads to beneficial effects flowing ‘downstream’ in the reduction in
dental treatment required due to a reduction in caries prevalence in
the population.

Caries risk
The ability to determine susceptibility to dental caries on either a
population or individual patient basis would offer a number of
advantages.
10 • C L I N I C A L D E N T I S T RY

Population basis. Permits developing appropriate policies and strat-

egies which seek to target resources, the location of clinics and the
implementation of preventive programmes.
Individual basis. Determines the need for caries control measures
such as socioeconomic factors, existing caries status, clinical judge-
ment of dental professional, the timing of dental recall appointments,
decisions as to suitability for advanced restorations, suitability for
orthodontic treatment.
Various tests have been devised for determining caries risk such as:
• counts of salivary lactobacilli (Dentocult LB), mutans streptococci
(Dentocult SM)
• tests of salivary buffering capacity (Dentobuff).
These tests have met with limited success as, due to the multifactorial
aetiology of dental caries, variation precludes accuracy and consist-
ent estimation of the caries susceptibility of an individual patient at
the chairside. The clinical judgement of the dental clinician, current
caries experience and socioeconomic factors of the patients have
proven the most reliable indicators of caries risk assessment. Deter-
mination of disease risk is an important factor in determining how
frequently patients should attend for preventive dental care such as
fluoride varnish applications, fissure sealants, etc.

Diet and dental caries (see also Chapter 3)

Evidence that sugar causes caries
There is clear and extensive evidence of the relationship between the
frequency and amount of sugar consumption and the prevalence and
severity of dental caries:
• epidemiological data show a correlation between sugar consump-
tion and caries on a national basis
• caries prevalence is higher in communities with high sugar
intake, e.g. sugar cane and confectionery industry workers
• caries prevalence increases following introduction of a sugar-
containing diet in isolated communities, e.g. the Inuit, island
communities such as Tristan da Cunha
• experimental clinical studies (such as Vipeholm Study) investigat-
ing the relationship between sugar intake and dental caries show
positive correlation between consumption of sugar (between
meals and at meals) and caries increment
• caries decreases following restriction of sugar, e.g. wartime diets.
Recently a number of research papers have argued that the increased
availability of fluoride has lessened the impact of sugar in the aetiol-
ogy of dental caries. However, there can be little doubt that a diet rich
 Dental public health, epidemiology and prevention • 11

pH
Plaque pH
Critical pH 5.5
Safe Net loss of calcium and phosphate ions below critical pH
zone

Danger
zone

6 7 8 9 10 11 12
Bottle Breakfast Snack Sippy cup Sippy cup Lunch
Figure 1.4 The effect of repeated sugar consumption.

in sugar, particularly if consumed at frequent intervals, will result in

caries development.

Factors influencing cariogenicity of foods

Cariogenic potential is related to consistency: sticky retentive foods
are more cariogenic than liquid non-retentive forms, e.g. toffee is
more cariogenic than chocolate.
The frequency of consumption is crucial. Snacking or ‘grazing’ results
in plaque pH being below the point where net outflow of calcium and
phosphate ions from the tooth surface occurs for prolonged periods
(Figure 1.4).

Dietary advice
The factors related to changing behaviour are particularly important
in encouraging patients to adopt a less cariogenic diet. Effective
dietary counselling requires knowledge of a patient’s habits relating
to non-milk extrinsic sugar consumption.

Diet diary
• Useful for those with high caries experience
• Must encourage patient to complete accurately
• Should cover a 3-day period including either Saturday or Sunday
• When completed, analyse with patient; highlight cariogenic food-
stuffs, particularly hidden sugars
• Allows formulation of personal advice for each individual
• Where possible, advise patient (and parent) in both written and
verbal form.

The ultimate message is ‘eat less sugar and eat sugar

less often’.
12 • C L I N I C A L D E N T I S T RY

Non-sugar sweeteners. Non-cariogenic and useful sugar

substitutes.
Bulk sweeteners, e.g. sorbitol and xylitol, provide calories and bulk;
useful as sugar substitutes in confectionery, chewing gum and
medicines.
Intense sweeteners, e.g. saccharin and aspartame are calorie free;
popular in ‘slimmers’ foods’.
From a dental point of view, whilst bulk and intense sweeteners
are non-cariogenic and therefore useful sugar substitutes, use of arti-
ficial sweeteners also perpetuates the craving for sweet foods.
‘Tooth-friendly’ sweets. Identified by the ‘tooth-friendly’ logo, these
sweets contain non-sugar sweeteners. Their use should be restricted
in small children due to possible adverse effects on the gastrointesti-
nal system (e.g. diarrhoea).
Chewing-gum. Sugar-free chewing-gum stimulates saliva and thus
increases salivary buffers and enhances washout of sugar. May be of
benefit in some patients, but should not be viewed as a prime caries-
preventive measure.
Carbonated beverages. Carbonated drinks have a pH of 2–3 and
can cause marked loss of tooth structure via erosion – an increasing
problem in teenagers. Even ‘diet’ varieties can lead to erosion.
Detersive foodstuffs. Contrary to previous beliefs, detersive foods
are of little or no benefit in removal of plaque. Effective plaque
removal is dependent on tooth-brushing. However, carrots, apples,
etc. are preferable to high-sugar snacks.

Fluoride
Evidence for the efficacy of fluoride in the prevention of dental caries
is incontrovertible. A series of systematic reviews published by the
Cochrane Library have concluded that children who brush their
teeth at least once a day with toothpaste that contains fluoride will
have less tooth decay. These reviews have also shown that fluoride
has a caries preventive action when delivered in vehicles other than
toothpaste. Public Health England (PHE) has published a report
‘Water fluoridation health monitoring report for England 2014’. The
report provides further reassurance that water fluoridation is a safe
and effective public health measure. PHE continues to keep the evi-
dence base under review.

Modes of action
Systemic (pre-eruptive) effect. Fluoride ions are incorporated into
enamel structure in the form of fluor-apatite during tooth formation.
This decreases the mineral solubility.
 Dental public health, epidemiology and prevention • 13

Topical (post-eruptive) effect. Fluoride ions are associated with the

tooth surface post eruption. The fluoride interaction with hydroxyl-
apatite is complex; fluoride interacts with the tooth structure either
by incorporation into the crystal lattice or by binding to crystal sur-
faces. Calcium fluoride at the tooth surface not only reduces the solu-
bility of the apatite but also encourages remineralization.
Whilst fluoride may also cause decreased acid production by cari-
ogenic bacteria, its effect on mineral solubility is of much greater
clinical significance.
Historically it was thought that fluoride availability during tooth
formation for incorporation into the hydroxyl-apatite was most
important. It is now realized the topical effect at the tooth surface
post eruption is very important. Thus, methods that apply fluoride on
a regular (daily) basis are most effective against caries.

Evidence that fluoride prevents caries

• Caries prevalence is lower in areas where fluoride is present natu-
rally in the water supply at the optimum level of 1 ppm (part per
million).
• Addition of fluoride to the water supply to the optimum level of
1 ppm is effective in reducing the prevalence of dental caries.
• Fluoride-containing toothpastes are effective in preventing caries.
• Fluoridated milk is beneficial to school children, especially their
permanent dentition
• Supervised regular use of fluoride mouth-rinse is associated with
a reduction in caries increment in children.

Mechanisms for delivering fluoride

Water fluoridation
Fluoridation of the public water supply at 1 ppm has been shown in
numerous studies to reduce caries incidence. It is more effective
against caries on smooth surfaces of teeth than in pits and fissures.
However, in the UK, despite its proven benefits and safety, only 10%
of the population receive fluoridated water.

Fluoride toothpaste
The main mechanism whereby fluoride is delivered is via toothpaste
(dentifrice). Most formulations contain sodium fluoride (NaF) or
sodium monofluorophosphate (SMFP) or a combination of both, at a
concentration of either 1000 or 1500 ppm. Used twice daily, these
can reduce caries incidence by around 30%. Restrict the amount of
toothpaste used by children under the age of three to a smear of
toothpaste at each brushing. The amount of toothpaste can be
increased to a pea-sized amount for children aged three to six years.
14 • C L I N I C A L D E N T I S T RY

Children’s formulations containing either 125 or 550 ppm F− are

available, but there is little evidence that at this concentration these
formulations are truly effective in preventing caries, particularly in
high-risk children, and therefore they are not recommended. Chil-
dren under the age of three years should be using fluoridated tooth-
paste with at least a minimum of 1000 ppm F− and those over the age
of three should be using more than 1000 ppm F−. All children over
the age of six and all adults should be recommended to use fluori-
dated toothpaste with at least 1350 ppm fluoride.
For those 10+ years with active caries and at continual high risk,
2800 ppm fluoride toothpaste can be prescribed by dentists. For those
16+ years with active disease and at continual high risk, dentists can
prescribe either 2800 ppm or 5000 ppm fluoride toothpaste.
Toothpastes are available in mild minty taste or fruity flavours
but mint flavours are preferred in order to discourage children from
eating the paste.

Fluoride drops and tablets

Given during the period of tooth formation, fluoride drops and tablets
can exert both a systemic and topical effect. Dosage is related to age
and the fluoride content of the local water supply. The regimen cur-
rently recommended in the British National Formulary (BNF) is shown
in Table 1.1.
Give fluoride tablets last thing at night and allow to dissolve slowly
in the mouth.
If using fluoride toothpaste, any additional supplementation is
required only in those judged at high risk of developing caries.
However, to be effective, supplements must be given over a prolonged
period and compliance can be problematic.

Fluoridated salt
Fluoridated salt has been used successfully as a caries preventive
measure in Switzerland and France. However, given the general

TABLE 1.1 Recommended daily dosage of fluoride tablets and drops

(mg F/day), related to age and concentration of fluoride in the
drinking water
Water F Water F Water F
Age (ppm) <0.3 (ppm) 0.3–0.7 (ppm) >0.7
0–6 months 0 0 0
6 months–3 years 0.25 0 0
3–6 years 0.5 0.25 0
Over 6 years 1 0.5 0
 Dental public health, epidemiology and prevention • 15

health promotion message of decreased salt intake and the fact that
most salt is added during the manufacturing process, this is unlikely
to be a realistic mechanism for community fluoridation.

Fluoridated milk/fruit juices

Whilst proven to be successful vehicles for fluoride delivery, these are
difficult to implement as a public health measure. A recent systematic
review concluded that while there were insufficient studies with good
quality evidence examining the effects of fluoridated milk in prevent-
ing dental caries, the included studies suggested that fluoridated milk
was beneficial to school children, especially their permanent denti-
tion. The data need to be supplemented by further RCTs (randomized
controlled trials) to provide the highest level of evidence for practice.
The disadvantage of fruit juices is that they are acidic.

Fluoride gels
Topically applied in individual trays. Given current views on the
importance of the frequency of fluoride application, if fluoride
therapy is required in addition to toothpaste, mouthwashes are
preferred.

Fluoride mouthwashes
Most contain NaF at 0.05% for daily use or 0.2% for weekly use,
although daily use is preferred. Patients should be advised to use fluo-
ride mouth rinse at a different time to brushing.
Indications. Teenagers with high caries activity; patients prone to
root caries, e.g. xerostomia; non-carious tooth surface loss; dentine
hypersensitivity. However, there is some concern and evidence that
alcohol-containing mouthwashes may be carcinogenic.

Fluoride varnishes
Contain F− in an alcoholic solution of natural varnishes at 2.2% NaF
(Duraphat®). Fluoride varnishes applied professionally two to four
times a year have the ability to substantially reduce tooth decay in
children. Fluoride varnish is one of the best options for increasing the
availability of topical fluoride, regardless of the levels of fluoride in
the water supply. A number of systematic reviews conclude that
applications two or more times a year produce a mean reduction in
caries increment of 37% in the primary dentition and 43% in the
permanent.

Fluoride foams
Used in a similar form to fluoride varnishes, these are professionally
applied to promote remineralization of early enamel caries and to
encourage remineralization of exposed dentine.
16 • C L I N I C A L D E N T I S T RY

Fluorosis
Fluorosis or mottled enamel may occur due to excessive intake of
fluoride during tooth formation. In the UK, fluorosis is most likely to
occur due to excessive consumption of fluoridated toothpaste. For
this reason, it is vital that the volume of toothpaste used by children
should be restricted to a pea size/smear amount (according to age) at
each brushing and children discouraged from swallowing paste.
Fluorosis results in hypomineralization and affects mainly the per-
manent dentition. Effects range from barely noticeable ‘white flecks’,
to brown stains in more severe cases.
Mild forms may diminish with time but can be markedly improved
by etching and polishing. Most severe cases may require veneers.

Safety of fluoride
The safety of fluoride at 1 ppm in the public water supply has been
the subject of numerous studies and has been established. However,
acute toxicity (particularly from the ingestion of fluoride toothpaste)
may occur above 5 mg F−/kg body weight.
Antidote. <5 mg F−/kg body weight – drink large volume of milk and
seek medical advice; >5 mg F−/kg body weight – refer to hospital for
gastric lavage without delay.

Fluoride tablets, toothpaste and mouthwashes should

always be stored and kept out of the sight and reach of
children or people with learning impairment.

Smoking and oral health

The adverse impact of smoking on health is well recognized. Smoking
can have many adverse effects on oral health (Box 1.1).
Cigarette smoking is the greatest single cause of illness and prema-
ture death in the UK: about 100 000 people in the UK die each year
due to smoking. Long-term smokers, on average, have life expectancy
about 10 years less than non-smokers. Worldwide, tobacco use
causes more than 5 million deaths per year and current trends show
that tobacco use will cause more than 8 million deaths annually by
2030. Prevalence of smoking may be decreasing in some people in
the developed world but is increasing in the developing world.
Stopping smoking has significant benefits both for general and oral
health. The dental team has a key role to play in helping smoking
cessation. As smoking has such a dramatic effect on the patients’ oral
health, the most effective way of ensuring they can access local stop
smoking services is to give very brief advice (30 seconds). ‘Ask, Advise
 Dental public health, epidemiology and prevention • 17

Box 1.1 The effects of smoking on oral health

• There is a dose–response relationship between tobacco use and risk of
mouth cancer
• There is some evidence that stopping smoking after diagnosis improves
mouth cancer survival
• White patches occur on the oral mucosa six times more frequently in
smokers than non-smokers
• Smoking causes cellular changes within the oral epithelium, which most
commonly presents clinically as smokers’ keratosis
• Smokers are 2.5 to 5 times more likely to develop periodontal disease than
non-smokers. These odds may be even higher in younger people
• There is evidence of a direct correlation between the number of cigarettes
smoked and the risk of developing periodontitis
• Reduced gingival redness and oedema in smokers (due to the vasoconstric-
tive effects of nicotine) may mask underlying attachment loss
• Acute necrotizing ulcerative gingivitis occurs predominantly in smokers
• Sinusitis occurs 75% more frequently in smokers than in non-smokers
• Taste and olfactory senses are dulled in smokers
• Tooth staining is more common in smokers
• Smokers are predisposed to halitosis
• Wound healing is delayed in smokers – dry sockets occur more commonly
in smokers
• Osseointegrated implants are significantly more likely to fail in patients who
smoke
• The outcome of most forms of periodontal therapy, including root planing,
flap surgery, guided tissue regeneration and local antimicrobial therapy, is
less favourable in smokers than in non-smokers

and Act’ will give them the best chance to successfully stop smoking
(PHE 2014):
1. Establish and record smoking status (ASK)
2. Advise on the personal benefits of quitting (ADVISE)
3. Offer help by signposting to local stop smoking service (ACT)
Follow-up of patients is important and the dental team is well placed
to assist with this because of their ongoing and regular contact with
patients (Figure 1.5).
There is good evidence that Nicotine Replacement Therapy (NRT)
in the form of patches, chewing-gum and nasal sprays increases the
quit success rates. Other drugs, such as bupropion and varenicline,
may also help smokers quit.

Smokeless tobacco and oral health

Smokeless tobacco (ST) products are those that are chewed, sucked
or inhaled. There is no scientific evidence that using ST either helps
a person quit smoking or is a safer alternative to smoking. ST con-
tains carcinogens, and therefore increases the risk of mouth cancer,
18 • C L I N I C A L D E N T I S T RY

Precontemplation

Maintenance Contemplation

Action Preparation

Figure 1.5 Stages of behavioural changes.

potentially malignant disorders and gingival recession. Many forms

of ST also contain sugar and its use is associated with tooth discolora-
tion and halitosis.
The use of ST is particularly common amongst south Asian com-
munities (e.g. people with ancestral links to Bangladesh, India, Nepal,
Pakistan or Sri Lanka), in particular chewing tobacco which is either
chewed alone or with betel quid/paan. NICE has published guidelines
on ST cessation in South Asian communities (https://www.nice.org
.uk/guidance/ph39). The recommendations were developed by the
Public Health Interventions Advisory Committee (PHIAC) and are
based on the best available scientific evidence.
Dental professionals have a crucial role to play in raising aware-
ness of the dangers to oral health associated with the use of ST and
should ensure the very brief advise ‘Ask, Advise and Act’ is also imple-
mented for these patients as local stop smoking services will usually
also help these patients quit, too.

Electronic cigarettes and oral health

E-cigarettes, short for electronic cigarettes, are battery-powered
devices that look like conventional cigarettes, but more commonly
look very different, as the technology develops. E-cigarettes provide
doses of vaporized substances to the user in an aerosol form. The
devices contain a heating element that vaporizes a liquid solution.
Depending on the brand of e-cigarettes, the liquid solutions may
contain nicotine and flavourings.
Whilst e-cigarettes are certainly much lower in the amount of
toxins that they contain compared to a standard cigarette, they are
certainly not free of all chemicals. The overall effect of e-cigarette use
 Dental public health, epidemiology and prevention • 19

on public health is estimated to be at least 95% less than smoking

tobacco cigarettes (Public Health England 2015). There is also no
current evidence that e-cigarette emissions cause any significant
environmental harm to others. There is little documented evidence
regarding the oral effects of e-cigarette use. Systemic effects of
e-cigarette use need further research.

Hookah (shisha) and oral health

A hookah (also known as a water pipe, nargeela, shisha, okka,
kalyan, ghelyoon or hubble-bubble) is a device for smoking. The
hookah operates by water-filtration and indirect heat. It is commonly
used in peoples from the Arabian Peninsula, Turkey, India, Pakistan
and some regions of China, and is becoming more popular in
younger generations with the establishment of special bars in the UK
and elsewhere. Hookah smoking is often considered a safe and harm-
less alternative to cigarette smoking. As a result more and more
people are smoking shisha, particularly students and people in
higher education.
Smoking through water, using flavoured tobacco and at lower
temperatures does not mean that water-pipe smoking is harmless.
Hookah smoking (including flavoured products) causes raised carbon
monoxide in the atmosphere (CO) and in blood levels (COHb) that are
known to be harmful in cigarette smoking and can cause cardiovas-
cular disease, respiratory problems and have an effect on those who
are in the same environment. Sharing nozzles can also contribute to
spread of infections. At the moment there is no national policy to
raise awareness about hookah smoking and many people do not
understand that it may have a harmful effect on their own and other
people’s health around them. It is important that dental practitioners
help to dispel myths about shisha’s alleged safety as it can cause
mouth cancer and infections.

Alcohol consumption and oral health

High alcohol intake is associated with an increased risk of developing
mouth cancer, potentially malignant disorders, periodontal disease,
caries and xerostomia. Used in combination, alcohol and tobacco
exert a synergistic effect that substantially increases the risk for
mouth cancer.
Alcoholism may lead to trauma, and can damage the liver and
bone marrow resulting in excessive bleeding during dental treat-
ment. Dental anaesthetics may not work as well in the alcohol abuser
and may be carried into the bloodstream more rapidly, requiring
additional injections.
Both the Royal College of General Practitioners and NICE (the
National Institute for Health and Care Excellence) recommend that
20 • C L I N I C A L D E N T I S T RY

primary medical practitioners screen all patients for alcohol misuse

using a questionnaire. It has been suggested that a similar type
of questionnaire could be asked by a dentist (Figure 1.6). Typical
questions might be:
• How often do you have a drink containing alcohol?
• How many units of alcohol do you drink on a typical day?

Please tell us about your alcohol consumption

Unit scoring system
Questions (please circle your answers) 0 1 2 3 4
Never Monthly or 2 – 4 times 2 – 4 times 4+ times
How often do you have a drink containing alcohol? (go to Page 4) per month per week per week
less
How many units of alcohol do you drink on a typical day 1–2 3–4 5–6 7–9 10+
when you are drinking?

How often have you had 6 or more units if female, or 8 or Less than Daily or
Never Monthly Weekly almost
more if male, on a single occasion in the last year? monthly
daily

How often during the last year have you found that you Less than Daily or
Never Monthly Weekly almost
were not able to stop drinking once you had started? monthly
daily

How often during the last year you failed to do what was Less than Daily or
Never Monthly Weekly almost
normally expected from you because of your drinking? monthly
daily
How often during the last year have you needed an Less than Daily or
alcoholic drink in the morning to get yourself going after Never Monthly Weekly almost
monthly
a heavy drinking session? daily

How often during the last year have you had a feeling of Less than Daily or
Never Monthly Weekly almost
guilt or remorse after drinking? monthly
daily
How often during the last year have you been unable to Less than Daily or
remember what happened the night before because you Never Monthly Weekly almost
monthly
had been drinking? daily

Have you or somebody else been injured as a result of Yes, but Yes, during
No not in the the last
your drinking?
last year year
Has a relative or friend, doctor or other health worker Yes, but Yes, during
been concerned about your drinking or suggested you No not in the the last
cut down? last year year

1 Unit 1.5 Units 2 Units 3 Units 9 Units 30 Units

Normal beer Small glass Strong beer Medium glass Strong beer Bottle of wine Bottle of spirits
half pint of wine half pint of wine Large bottle/can (750ml) 12.5% (750ml) 40%
(284ml) 4% (125ml) 12.5% (284ml) 6.5% (175ml) 12.5% (440ml) 6.5%

Single spirit shot Alcopops bottle Normal beer Large glass

(25ml) 40% (275ml) 5.5% Large bottle/can of wine
(440ml) 4.5% (250ml) 12.5%

Figure 1.6 Alcohol units scoring system. Adapted from http://www

.alcohollearningcentre.org.uk/_library/AUDIT-C.doc with permission from
Alcohol Learning Centre, Public Health England.
 Dental public health, epidemiology and prevention • 21

• How often do you have six or more units of alcohol in a single

day?
• In the last year, have you failed to do something that you would
normally do because of drinking too much alcohol?
• How often in the last year were you unable to remember what
happened the previous night because of drinking too much
alcohol?
Scoring systems provided with the questionnaires would help dentists
identify patients at risk who would benefit from intervention. Dental
professionals could provide these patients with motivational advice
and information leaflets. Those with more severe alcohol misuse
would be referred to the patient’s medical practitioner.

Other substance abuse and oral health

Stimulants like ecstasy, amphetamines and cocaine are known to
cause individuals to clench and grind their teeth, resulting in tooth
wear, temporomandibular disorders, loose and cracked teeth and
damage to the tooth roots and gums. Users of stimulants often also
experience chronic dry mouth resulting in increased consumption of
sugary drinks. Many drugs cause users to crave sweet foods but their
lifestyle often ignores the importance of oral care. Methampheta-
mine causes the saliva glands to stop producing saliva resulting in an
extremely dry mouth and enamel damage (‘meth mouth’). Heroin is
known to cause serious oral health problems and in chronic long-
term users, carious and missing teeth and periodontal disease are
often evident.
Dental practice setting has the potential to provide prevention of
substance abuse through patient counselling on the hazards of
drugs; this is most likely to occur when a problem already appeared
to be present. It is also important to liaise with the patient’s medical
practitioner if the patient has been prescribed methadone as a sub-
stitute for heroin: to ensure that the methadone being prescribed is
sugar-free.
Opioids are analgesics that have potential for misuse, abuse or
addiction. As prescribers, dentists can minimize the potential for
misuse or abuse through use of peer-reviewed guidelines for analge-
sia, patient education, careful patient assessment and referral for
substance abuse treatment when indicated.

HIV infection and oral health

Oral problems can be common in people with HIV/AIDS, and the
majority of oral conditions arise because of the immune defects. Oral
disease is often the first manifestation of HIV infection. People with
HIV are more susceptible to oral warts (which can also progress to
22 • C L I N I C A L D E N T I S T RY

mouth cancer), herpes (‘cold sores’), oral hairy leukoplakia; candidia-

sis (thrush), ulcers and periodontal disease (periodontitis and gingi-
vitis). In addition, bacterial infections that begin in the mouth can
become more serious and, if not treated, spread into the bloodstream.
This can be particularly dangerous for people living with HIV/AIDS
who may have compromised immune systems. People with HIV/
AIDS may also experience dry mouth, which increases the risk of
caries and candidiasis and can make chewing, eating, swallowing,
and even talking difficult. Some HIV medications can cause dry
mouth. Therefore dental practitioners must stress good oral hygiene,
if necessary establish a plan for regular visits for oral examinations
and periodontal therapy and treatment plan for dry mouth.
In some countries, for example in the USA, some dental practition-
ers offer oral HIV tests on saliva.

Prevention of dental neglect

Dental neglect is a proxy indicator of broader neglect. Dental neglect
is the wilful or persistent failure to meet a child’s or vulnerable per-
son’s basic oral health needs by not seeking or following through
with necessary treatment to ensure a level of oral health that allows
function and oral health (freedom from pain and infection). Dental
neglect can result in the impairment of oral or general health or
development. Roles of dental professionals in the accurate, timely
assessment of children for dental neglect means that they are poten-
tial catalysts in securing a child’s overall safety and well-being.
In 2009, NICE guidelines officially recognized dental neglect as a
type of child neglect, something that raised the profile of child oral
health on the public health agenda. The NICE recommendations are
related to two aspects of dental neglect:
1. the parent’s persistent failure to obtain NHS treatment for their
child’s dental caries when such NHS dental services were availa-
ble, and
2. the possibility of child maltreatment due to an absent or unjustifi-
able explanation for a child’s oral injury.
Supervised neglect by dental professionals is a situation where a
patient’s oral health has been allowed to deteriorate over a period of
time, despite regular attendances to the dental clinician who is
responsible for the patient’s care and treatment. Some dental clini-
cians mistakenly believe that damage to a child’s deciduous dentition
is not worth repairing, despite the fact that the consequences could
include high morbidity and knowingly putting the child at risk of
pain and suffering.
Every dental professional has a duty of care to exercise a reason-
able level of skill and competence, when treating each patient under
their care. Failing to provide necessary treatment is one way in which
 Dental public health, epidemiology and prevention • 23

this duty of care can be breached; recommending or providing

unnecessary treatment falls at the other extreme, but is still a breach
of a clinician’s duty of care.

Sport trauma
Dentistry plays an important role in preventing serious injury to the
mouth during contact sports by advising patients to take care and to
wear mouthguards which help protect against injuries to the cheeks,
gums, jaws and teeth.

Temporomandibular disorders
Local mechanical factors such as teeth grinding may play an aetio-
logical role in the development of temporomandibular disorders
(TMD). Dentists should note evidence of toothwear and advise
patients on measures to prevent trauma and bruxism. Night mouth-
guards can be prescribed to prevent future tooth wear (see Chapter
18; removable prosthodontics).

Frequency of dental attendance

An important consideration in the prevention of oral disease is the
frequency with which patients should attend for a routine oral exam-
ination, or ‘check-up’. Traditionally patients were advised to visit the
dentist on a 6-monthly basis. Currently there is no evidence to
support or refute the practice of encouraging patients to attend for
dental check-ups at 6-monthly intervals. However, it is recognized
that patients differ in their risk of oral disease, and as oral health
improves, a ‘one size fits all’ recall interval is no longer appropriate.
Recall intervals should therefore be tailored to individual patients’
needs or circumstances.
In England, NICE has issued guidance on the timing of dental
recalls. This recommends that the interval between oral health
reviews should be determined specifically for each patient and tai-
lored to individual needs based on an assessment of disease levels and
risk of or from dental disease. For patients younger than 18 years,
recall intervals can vary between 3 and 12 months. For those over
18 years, intervals can range between 3 and 24 months.
A guiding principle in deciding on recall intervals is to start with
a short interval and then gradually increase if the patient’s oral
health remains stable and risk factors remain constant or reduce.

Routine scale and polish

Currently there is insufficient evidence of clinical effectiveness and
cost effectiveness of ‘routine scaling and polishing’ and the ‘optimal’
24 • C L I N I C A L D E N T I S T RY

frequency at which it should be provided for healthy adults. However

some positive effects of dental scaling are found for chronic periodon-
tal disease. As the magnitude of differences between 3-monthly and
annual scaling after one year in published literature is small, evi-
dence confirming these findings in the general dental population is
required before a change in policy on dental scaling interval can be
recommended.

Prevention in older patients

As oral health improves, an increasing number of older patients will
retain their teeth for longer. In addition, demographic changes have
seen the total number of people of pensionable age in the UK increase
by 4.2% between 1985 and 2001. By 2025 this will have increased
by 31.1%. Thus, care of the older patient is increasingly important
to the dental profession.
Furthermore, the independent review of NHS dental services in
England (2009) also identified a growing population of older people
who have experienced high levels of disease which have been treated
by fillings and other restorations (the ‘heavy metal generation’) and
who will have high maintenance needs as they age further.

Factors complicating disease prevention

in older patients
Plaque control
Gingival recession; migrated and tilted teeth increase the number of
inaccessible surfaces. Partial dentures increase plaque retention.
Poor eyesight and reduced dexterity make toothbrushing difficult.
Polypharmacy is common in the older patient; some drugs reduce
salivary flow.

Diet
Increased tendency to snacking – cakes and biscuits. Particularly
prone to recurrent caries and root caries.

Denture care
Encourage removal of dentures at night and good denture hygiene.
Emphasize the importance of annual dental examinations, even if
edentulous, because this permits early detection of mucosal disease
(e.g. mouth cancer).

Advanced restorative care

Improved quality of life at old age will demand tooth retention and
consequently the need for restorative care. The growing older popula-
tion may have acquired advanced restorative care such as crowns,
 Dental public health, epidemiology and prevention • 25

bridges and implants in their working age which requires mainte-

nance in their older age (‘the heavy metal brigade’).

Pregnancy and oral health

Pregnant women require additional dental hygiene care due to hor-
monal changes which can affect oral health. Some pregnant women
experience inflamed and bleeding gums, termed ‘pregnancy gingivi-
tis’ which can start within the second month of pregnancy. Pregnant
women are therefore more susceptible to developing periodontal
disease during the time when hormonal fluctuations occur. Some
women also experience a nodular inflammatory reaction on their
gums known as a pregnancy granuloma. Dry mouth is another
common complaint, but can be remedied by drinking plenty of water
and using saliva stimulants available over the counter to stimulate
saliva flow.
Other oral health problems may include tooth erosion as a result
of repeated gastric acid exposure from severe morning sickness. If
pregnant women are experiencing severe and recurrent morning
sickness, they should be advised to rinse the mouth afterwards with
water or a fluoride mouthwash and wait for at least 30 minutes
before toothbrushing. Women who suffer from morning sickness
may also want to eat ‘little and often’ but should try to avoid sugary
and acidic foods and drinks between meals to protect teeth against
caries.
It is a myth that calcium is lost from the mother’s teeth during
pregnancy. The calcium a baby needs is provided by the mother’s diet.
If dietary calcium were to be inadequate, however, the body accesses
this mineral from bone stores. An adequate dietary intake of foods
such as dairy products and green leafy vegetables will help to ensure
sufficient calcium intake during pregnancy.
Smoking and drinking in pregnancy can lead to an underweight
baby and also affect the unborn baby’s dental health. Maternal
smoking increases the risk of cleft lip/palate, as well as other birth
defects, in the offspring. Maternal oral health may negatively affect
pregnancy outcomes.

Oral health in special population groups

(see also Chapter 20)
Patients in special population groups such as immunocompromised
and hospitalized patients are at greater risk for general morbidity due
to oral infections. Individuals with diabetes or inflammatory diseases
such as rheumatoid arthritis and ankylosing spondylitis are at
greater risk for periodontal disease and therefore require additional
preventative measures. There may be an association between
26 • C L I N I C A L D E N T I S T RY

periodontal diseases and cardiovascular disease and stroke, and a

range of other systemic issues. Children with a cleft lip/palate are
more vulnerable to tooth decay, so it is important to encourage them
to practise good oral hygiene.
Children and adults with impairments have the same entitlement
to good oral health as the rest of the population but there is evidence
that they are at risk from higher levels of oral health need and bar-
riers to care (see Chapter 20). Valuing People’s Oral Health (DH
2007) best practice guidance specifically addresses their oral health
needs and makes evidence-based recommendations on how oral
health may be improved.

Conclusion
The dental profession has an important role in helping patients to
adopt oral health-promoting behaviour. It is essential that dental
professionals understand the need for prevention and provide
evidence-based guidance and support.

References
DH, 2007. Valuing people’s oral health: a good practice guide for improving the oral
health of disabled children and adults. DH Publications, London.
Kay, E.J., Locker, D., 1996. Is dental health education effective? A systematic review
of current evidence. Community Dent. Oral Epidemiol. 24 (4), 231–235.
NICE, 2009. Child maltreatment: when to suspect maltreatment in under 16s
(Update). NICE clinical guideline 89. <https://www.nice.org.uk/guidance/cg89>
[NICE guideline].
Office for National Statistics. Social Survey Division, 2011. Children’s dental health
survey, 2003. [data collection]. UK Data Service. SN: 6764, <http://dx.doi.org/
10.5255/UKDA-SN-6764-1> (accessed 23.03.15.).
Public Health England, 2014. Water fluoridation health monitoring report
for England 2014. <https://www.gov.uk/government/publications/water
-fluoridation-health-monitoring-report-for-england-2014> (accessed 23.03.
15.).
Public Health England, 2015. https://www.gov.uk/government/uploads/system/
uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A
_report_commissioned_by_Public_Health_England_FINAL.pdf>.
The Health and Social Care Information Centre, 2011. <http://www.hscic.gov.uk/
pubs/dentalsurveyfullreport09>.
The Marmot Review, 2010. <http://www.instituteofhealthequity.org/projects/fair
-society-healthy-lives-the-marmot-review>.
 2
Social and
psychological aspects
of dental care

The social determinants of oral Dental anxiety and

health 27 phobia 32
Communication and the dental Psychological management
team 29 of pain 35
Changing oral health-related
behaviour 31

The social determinants of oral health

Oral health has been defined as ‘a complete state of physical, psycho-
logical and social well being’. Despite criticism of this definition as
setting a standard of health which is unachievable, it does demon-
strate that health comprises more than simply the absence of disease
and encompasses physical and psychological well-being and the
ability to engage in valued social activities (such as work and relation-
ships). Oral health, and oral disease are not evenly distributed across
the population, certain groups are more likely to experience oral
disease than others, as discussed in Chapter 1. It is possible to char-
acterize those who are most likely to experience caries, periodontal
disease and other oral diseases on the basis of social factors (Watt &
Sheiham 1999). These inequalities are considered unjust.

1. Social class
Despite overall improvements in oral health over the last 50 years,
individuals from lower social classes as classified by occupation, those
who have lower levels of income, and those with less formal educa-
tion are all on average more likely to experience dental disease
(mainly caries and periodontal disease; Chapter 3) at all ages.

2. Gender
Men generally have higher levels of active dental disease than
women. Women are more likely to use preventive dental services.

3. Age
Edentulousness increases with age. Periodontal disease also shows
marked age-related trends.
28 • C L I N I C A L D E N T I S T RY

4. Disability status
Individuals with a wide range of physical and mental disabilities have
poorer oral health and access services less frequently than individu-
als without disabilities.

5. Ethnicity
The effect of ethnicity on oral health is difficult to differentiate from
the effect of social class, since individuals from minority ethnic com-
munities are over-represented in the lower social classes in the United
Kingdom. However, there is some evidence to suggest that ethnicity
does have an impact on oral health.

The dental team can be involved with seven actions that help reduce
inequalities (Watt et al 2013):
1. Understanding the oral health needs of the local population. The
needs of the population may not match the needs of those patients
who attend the practice. Practitioners should consider planning
services in the light of the whole population.
2. Focus on early life – the foundations of good health. In line with
the strategy for improving the overall population health, it is sug-
gested that particular focus is placed on improving the conditions
of children and young people so they have the basis for lifelong
oral health (Marmot 2010).
3. Ensuring equity of access and the quality of treatment outcomes.
Equity in treatment provision refers to the delivery of services in
relation to need, rather than equally. Those with the greatest need
require the greatest access. The ‘inverse care law’ suggests that
access to dental services has often been greatest amongst those
with the least need. By extension if individuals access services
they should also be given interventions of proven efficacy.
4. Delivering evidence-based clinical prevention. The guidance
Delivering Better Oral Health (DH 2012) provides advice and
support for delivering evidence-based clinical prevention, includ-
ing such interventions as the use of topical fluorides, etc.
5. Team approach. All members of the team should be involved in
the endeavour to reduce inequalities.
6. Link to health providers. Oral health should not be seen in isola-
tion. The underlying causes of dental disease, diet, smoking,
alcohol use, etc. are common to a range of diseases (Chapter 1).
The Common Risk Factor approach suggests that the dental team
should be engaged with wider health services to improve all
aspects of the health of their patients.
7. Advocacy – supporting action on the determinants of inequali-
ties. Dental healthcare professionals represent a substantial body
of opinion, who could act as advocates for policy changes to
support oral health. For example, lobbying for changes which
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INTRODUCTION NOTE III. clxxxv 29 Pravaraaena, alias

Tunjina alias Sreshthasena. 30 Hiranya man a. 31 Matrigupta. and
Tora(8) Indradevi, another queen, built a vihara called
Indrabhuvana, and a stupa having four halls. (9) Khadana, Masma
and other queens built other viharas, and called them after their
respective names. (1) built the temple of Pravaresvara, furnished
with a group of images of the divine mothers. (2) consecrated
various temples and laid foundations in the old capital. ;3) allotted to
the shrine of Pravaresa the territory of Trigarta. (1) Toramana struck
dinaras in his own name. (1) prohibited slaughter of animals
throughout the kingdom during his reign. (2) patronized the poet
Mentha, the author of Hayagrivavadha. (3) built and dedicated a
temple to Madhusudana . (Vishnu), and called it
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clxxxvi GAUDAVAHO. 32 Pravarasena II. Matriguptasvami,

the villages granted to which were afterwards (A.D. 814-863) given
by Mamma (IV. 702) to the family of his father-inlaw. (1) built the
temple of Jayasvami in his newcity. (2) built the first bridge of boats
across the Vitasta or Jhelum. (3) built a city, which he named
Pravarasenapura, on the site of the village of Saritaka, and
established five goddesses, viz., Srisadbhavasri and others. The city
stood only on the south of the Vitasta. (4) Jayendra, the maternal
uncle of the king, built the Jayendravihara and the Brihadbuddha• .
vihara. (5J his minister Moraka built the vihara called
Morakabhavana. (6) the shrines of Vardhamana and Visvakarma
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INTRODUCTION NOTE III. (consecrated by him ?) were the

beauties of his city (read ^Rf for fltJT%: in III. 359. M. Trover's
emendation is wild). (7) the king richly endowed every temple in his
city. 33 Yudhishthira (1) his ministers Sarvaratna, Jaya, and
Skandhagupta built viharas and chaityas. (2) Yajrendra, the son of
Jayendra, was also his minister, and built the town of
Bhavachchheda. (3) Kumarasena and others also were his ministers.
34 Narendraditya. (1) built a temple called Narendra svami. (2) Vajra
and Kanaka, the sons of Jayendra, were his ministers. (3) built an
edifice or library for the custody of manuscripts and called it after
himself (R^TT III. 387). 35 Ranaditya alias Tunjina (1) built two
excellent edifices called after himself and after his queen
Ranarambha, to receive two
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clxxxviii GAUDAVAHO. Lingains ; but established Hari in one

and Hara in the other. (2) built the temple of Ranesvara, dedicated
to Siva. Brahma, a siddha, performed the consecration at the
instance of the queen (read cpjf §-5^T III. 458), and established an
image called Brahmasattama in his honour. (3) consecrated the
shrines of Ranasvami and Ranararnbhadeva ( ? or Rambhadeva),
and built the matha of the Pasupatas on the top of the Pradyumna
mountain. (4) built a hospital for the sick. (5) consecrated a shrine
of the goddess Senamukht. (6) consecrated a shrine of ,-
Ranapurasvami, dedica'ted to the sun, in the « i 'town of
Simharotsika. (7 ) Amritaprabha, another ctf his queens, consecrated
the god Amri 
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INTRODUCTION— NOTE III. clxXXlX tcsvara to the right

side of Ranesa. (8) the same queen, Amritaprabha, placed an image
of Buddha in the vihara built by her namesake the queen of
Meghavahana. (M. Troyer's translation, " Binna, queen of king
Meghavahana," is characteristic of his work). 36 Vikramaditya (1) his
ministers were Brahma and Galuna. (2) the minister Brahma built
the matha called Brahmamatha. (3) Ratnavali, the wife of Galuna,
built a vihara. 37 Baladitya (1) conquered Vankala and established
therein a colony called Kalambya for the residence of Kashmirians.
(2) made the agrahara of Bhedara in the territory of Madava. (3) his
queen Bimba (read ft*3T with M. Troyer) consecrated a shrine of
Siva called Bimbesvara.
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CXC GAUDAVAHO. (4) Khankha, $atrughna and Malava,

brothers, who were his ministers, built mathas and temples, and also
a bridge. From the above analysis it will be seen, that out of the
seventeen kings, whose names are preserved and who belong to
what I call the non-historic period, the names of no less than
thirteen were connected with foundations, endowments, grants and
other moounients, many of which Kalhana must have seen, and of
others of which he must have read accounts then extant. In the
historic period treated in the first three Tarangas, out of the thirty-
seven kings no less than twenty-three had left numerous
monuments, grants and similar evidences of their time, their
administration, and their liberality. The writings connected with the
latter must have helped Kalhana to fix the order and the dates and
the durations of the reigns of a great number of them. Of course it is
possible that like Romulus from Rome, some of the kings, especially
among the earlier ones, may have been imagined from the
monuments, the real origin of these being forgotten. But looking to
the nature of the monuments and the probability of copper-plate
and other grants having existed, that theory cannot eliminate many
of the kings. One large class of miscellaneous inscriptions to which
the author refers, besides those on foundation stones, consecration
pillars, &c., is that of short inscriptions on objects of household
furniture, coins, arms, copper-plates of grants of lands ^and
allowances and similar things (purvabhubkartri- vasiusdsandni).
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INTRODUCTION — NOTE III. CXC1 It is well known that

old copper and brass vessels, s words, daggers, and other arms
have inscriptions, containing the names of kings and their ancestors.
These must, doubtless, have been used for the purpose of setting at
rest some doubts which had been raised in his mind by the
conflicting accounts found in the books consulted by him. Besides
the historical works written by contemporary chroniclers, which
Kalhana mentions and refers to, it is reasonable to suppose that he
must have read legendary stories like those of Gunadhya, connected
with ancient celebrities and with many of the sacred places in
Kashmir, so many of which appear to have been mentioned ia the
older chronicles of the Kashmirian kings. Though, however, there is -
no reason to suppose that Kalhana's materials were not ample, and
though the chronicles he used were written by contemporary
authors — a fact which deserves the highest consideration— it must
not be forgotten that he writes in verse and as a poet, and is liable
to the defects which usually attend compositions in verse on a
matter of fact subject. Though simple facts can be made the subject
of poetry, all facts are not fit to be expressed in poetry, and a writer
of verse is often apt to colour his narrative when it is likely to be
otherwise dull, by the addition or omission of certain particulars.
This has, doubtless, happened in the Edjatarangini, as it might have
happened in any similar poetical work, or even in a prose work
which treated of history from such an ancient date as B. C. 1184.
There appears good reason to believe, however, that
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CX Cll GAUDAVAHO. Kalhana's materials, though many of

them written by eye-witnesses themselves, were of a highly coloured
poetical character, and that much of his own poetry is probably due
to them. He must have given many incidents just as he found them
in older works. We may observe, however, to his credit, that though
he gives such incidents, even when of a miraculous nature, he often
feels, and does not hesita.te to tell us that he feels, ashamed in
narrating them in such a book as his Rdjatarangini. We may instance
the reign of Meghavahana A.D. 24 to 58, that is described as full of
righteousness and of tenderness for the life of all creatures. That
king prohibited the taking of life in his kingdom, and even led an
expedition into Ceylon, in order to put down by force the slaughter
of animals for any purpose whatsoever. He succeeded, and returned
to Kashmir. A Brahman brought to him one day the dead body of his
only son, and declared that the goddess Durga had killed him with
fever, because that she had not been given a victim, though she had
asked for one. The king determined to offer himself as a sacrifice to
the goddess, in order to induce her to restore the Brahman's son to
life. Durga appeared before him, however, in the night and
prevented him from sacrificing himself, and at once restored the
dead son of the Brahman to life again. ' Relating * this and similar
deeds of the king, though he belongs ' to modem times, deeds
which are considered possible ' among ignorant people only, we feel
ashamed.'* Again, referring to the various accounts of the manner in
which
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INTRODUCTION - NOTE III. CXciii f Lalitaditya must have

met with his death, Kalhana says, ' as one reads that this king
performed * very miraculous deeds, so one reads that his death *
also was very miraculous.'* We might also refer to the author's
remark on the older accounts of the cruelties of king Mihirakula,
whom previous writers had represented as having killed three crores
of people because he found so many women failing to prove their
chastity. Kalhana remarks : * this is what is well believed, in the *
opinion of others. In truth, however, it is impossible. * Of course the
slaughter of people by him was very 6 great, even if those cases
alone were considered where * he killed for good reasons. 't The
Rdjatarangini, we must recollect, was written in A.D. 1149-51, and
almost touches at its beginning that mythical period, in which the
war of the Mahdbhdrata is believed to have occurred. If Kalhana had
begun his narrative from that king, Gonarda I., who was a
contemporary of the Pandavas and the Kauravas, his work, at least
in its earlier parts, would have deserved no better credit, as a
historical chronicle, than the Mafidbhd'rata or the JPurdnas* But of a
period of 1266 years from the time of the war of the Hahdb/tdrata
he says nothing, except that he gives the names of seventeen out of
fifty-two kings who are believed to have reigned during that period.
Of the rest, he says, even the names are forgotten. Many of * ar^Tf
rTTR" ?qrr^ £fTP*r**r W ftTW I mfatft
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CXC1Y GADUAVAHO. those named are, doubtless, and

some we know to have been, historical personages, such as Asoka,
Hushka, Jushka, and Kanishka. Besides naming the seventeen kings
of this period, the author narrates such details of some of them as
tradition had preserved, and as was borne testimony to by some
very ancient monuments still extant in his time. But no dates or
periods of reigns are given of any of them. His predecessors had
recorded the dates and events of the reigns of kings beginning
withGonarda ILL. and Kalhana has, apparently on the authority of
previous historians, commenced his own chronicle proper from the
accession of that king. From B.C. 1184 to A.D. 1151 is, however, too
long a period for accurate record to have been preserved thereof.
Accordingly, while the history of the later parts of the period, say of
the part which begins with Durlabhavardhana alias Prajnaditya, the
first of a dynasty called the Nagas, appears to be reliable as to main
facts and the durations of reigns of the fortyeight kings who reigned
up to the time of Kalhana, the period previous to Durlabhavardhana
is — even besides the impossibility of Ranaditya — often marked by
statements as to length of reigns and to events, which are not free
from suspicion. The periods assigned to the twenty-one kings who
reigned from 1184 to 169 B.C., for a period of one thousand and
fourteen years, nine months and nine d'ay^, are too long to be
reliable, giving an average of % little over fortyceight years to each
king. Besides, the numbers of year^ of reigns are too round to
rightly demand credence at our hands as to the accuracy 01 most of
them. Gonarda III may have reigned 1184 B.C. and for
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INTRODUCTION — NOTE III. CXCV thirty-five years. Both

his date and the duration of his reign are probably correct, because
all accounts appear to have begun the chronicles of Kashmir from
that* king, so that they must have preserved them by an unbroken
tradition. Nay, it is even probable that from Gouarda III up to
Pratapaditya of the Vikramaditya dynasty the period given maybe
quite correct, having been based upon previous contemporary
records, inscriptions, and other authorities which Kalhana had before
him. But what is also highly probable is, that some mistake has
occurred as to the number of kings who reigned during that period
of one thousand and fourteen odd years. All the kings given are
historical, but they could not be all the kings that reigned during that
long period. Probably some of those fifty-two kings whose names
have been lost, and some among those whose names have been
preserved, have to be brought on to the list, but besides this being a
mere guess, it may be added that, unless undoubted evidence is
obtained to justify the breaking up of the list in favour of any of
those kings, all we can do is to doubt the accuracy of the list in its
details, and leave it undisturbed for the present. In the second group
(from 22 to 2,7) six kings reign for one hundred and ninety-two
years or a little more than thirty-eight years each on an average. As
the average is taken from a very small number of kings, the lengths
of reigns may not be very unlikely, but the taint of suspicion still
seems to hover over the list. The same remark about suspicion may
not be made as
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CXCVI OAUDAVAHO. to the nature of the third group of ten

kings (28— 37) ; for there nine kings reign over a period of two
hundred and seventy-two odd years, or just thirty years each king
on an average. But then the group contains one king who is put
down for the extraordinary period of three centuries I This period,
from A.D. 217 to 517, is obviously one of which no records were
forthcoming, and Kalhana7 s predecessors had only recorded the
name of one king during it. The period was perhaps one during
which Kashmir was subject to foreign rule, and no king ruled in that
country. No records were, therefore, kept, and so none were
forthcoming. Otherwise it is difficult to say why Kalhana should have
given the period as practically a blank in his narrative. We,
accustomed as we are to the care with which he sifts his authorities*
and averse as he is to put faith in miracles, can hardly suppose that
he arranged artificially the reigns of the list up to the predecessor*
of Ranaditya, in order to come into harmony with the historical dates
of his successors, or that for love of the miraculous he assigned to
that king a periocf of three hundred years. The names in the group
are all historical, and there is nothing in the narrative to excite
suspicions about the events which from this part of the chronicle
forward begin to be more and more detailed. But when we come to
the, ( fourth group, from 38 to54r the list seems to improve in every
respect. The lengths of reigns are moderate and quite probable ;
and what is of the utmost importance is, that towards the end of the
group Kalhana begin 3 to give, along with the durations of reigns,
the dates in the Laukika era of the Brihaspati cycle of the accession
and death of
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INTRODUCTION— NOTE (II. CXCVli eacli king. Not only

this, but the dates are often given henceforward of some of the
important events in the administration of several of the kings, and
this system he continues to the end of his narrative. Without doubt
Kalhana's materials became more plentiful, more detailed, and more
thoroughly historical from the beginning of the Karkotaka or Naga
dynasty, which came into power in A.D. 596. From this date to A.D.
1151 where the narrative leaves us, the dates and general nature of
the chronicle seems to be as reliable as can be expected under the
circumstances. My humble estimate, accordingly, of the value of the
RAjatardngini as a historical chronicle is, that it is fairly reliable up to
the end of the Gonarda dynasty, or end of the reign of BA,laditya,
A.D. 596, and is as accurate as we have a right to expect from the
commencement of the Karkotaka dynasty up to the year 1151 A.D.,
a period of some 555 years, Up to the end of the Gonardas,
whatever its defects are, they are patent, and Kalhanahas made no
endeavours to conceal them by any subtle means, as he might easily
have done, if he had intended to do so. I do not believe there is any
evidence to show, that the date of Gonarda III. is placed too early,
but it is likely that some kings have been lost to history even during
the time that elapsed between that king, and Durlabhavardhana. But
it does not appear that Kalhana took, a's he is alleged to have
done,* any liberty with the lengths of reigns or dates of kings with
whose administrations he dealt. Everything he * "To me ' only fv
story' carries more weight tl.an history made "on purpose, such as
we know Kalhana's history to have been." Piofessor Max Muller, India
: What can it teach us? page 356.
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CXCV111 UADUAVAHO. says, and everything that

independent evidence has taught us, shows that his mistakes and
defects — confined to the first three groups — are the mistakes and
defects of his predecessors, the writers of previous chronicles and
summaries. Greater mis takes and defects may be shown undeniably
hereafter in those groups, and may perhaps be corrected. Bat
nothing has hitherto been adduced which shows that Kalhana
shortened or lengthened the years of a single king simply to suit a
system of dates which he had adopted, not because it was correct,
but because it was convenient or conventional. I make this
statement because he has actually been charged with having done
so, and having purposely done so, and, indeed, to have written his
Rdjatarangmi for the purpose of enabling any of his readers also to
do the same. As the charge has been preferred by one for whose
opinions I have the highest and sincerest respect, it is not without
the greatest hesitation and reluctance that I have here ventured to
suggest that there are no facts to support the charge. Professor
Biihler says* : — "As regards the use of the contents of the Edjata"
rangini for the history of Kashmir and of India a great " deal remains
to be done for the earlier portion, up to " the beginning of the
Karkota dynasty. Kalhana's " chronology of the Gonandiya dynasties
is, as Professor " Wilson, Professor Lassen, and General Cunningham
{< have pointed out, valueless, ^n author who connects "the history
of his country with the imaginary dale of * See Bombay Branch,
Royal Asiatic Society's Journal, Extra Number, 1877, (Vol. XII.), in
which his excellent paper on Kashmir MSS. is given, pp. 58, 59.
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INTRODUCTION — NOTE III. CXC1X "a legendary event,

like the coronation of Yudhishthira, and boasts that his narrative
resembles a medicine, and is useful for increasing and diminishing
the (statements of previous writers regarding) kings, " place, and
time, must always be sharply controlled, " and deserves no credit
whatever in those portions of " his work where his narrative shows
any suspicious " figures or facts." The translation given at page clxxii
above of Kalhana's sloka I., 21, will have shown that his meaning is
very different, and he does not boast that his work is useful for
lengthening or shortening the periods of the Kashmirian kings or the
statements about their times or territories, but only that it will be
useful in furnishing a medicine in the shape of much consolatory and
instructive matter — events and sayings — to cure any kings who
shall hereafter suffer from the disease of the pride and arrogance of
prosperity, or the disease of grief at the loss of territory or the
adversity of their times. If the insolence of success and prosperity
should make them overbearing, the end of Nara I. alias Kinnara, of
Mihirakula, or of Yudhishthira the Blind, will teach them a lesson. If
they are depressed with grief at the loss of territory or by the
adversity of their subjects, wisdom, hope and consolation will be
afforded by the story of the restoration of the Gonardas in the
person of Megha'vahana or of Pra»v.arasena II. (who succeeded to
the heritage of his father after Matrigupta), or by the story of Jajja
and Jayapida, or by the story of the famine brought on by snow-
storms in the time of Tunjina, the son of .Jalaukas,* I have shown
my transla* Also sec I., 187-90, to which t,he author might refer for
the purpose of showing what rewards await virtuous kings.
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CC (UUDAVAHO* tion to several native scholars, and I am

assured that no other sense is possible. I lay stress upon the pro*
per meaning of the couplet being understoodj not because I wish to
prove — what nobody can prove-^-that Kalhanain no case misused
his materials* but because if the couplet is misinterpreted as
proposed, it will throw discredit upon the whole of whatever of the
historical there is in the Rdjatarangini. Already" such an eminent
scholar as Prof. Max Miiller,* has adopted the translation of my
honoured friend Dr. Buhler, and endorsed the view that Kalhana's
ideas of history are shown by that couplet, viz., that he could Write
an elaborate poem of more than eight thousand couplets, in order
that scholars might afterwards lengthen or shorten the statements
of Kashmirian chroniclers regarding kings, place and time, just as it
might please them or as they might find it necessary. Among the
speculations of M. Troyerf about the Rdjatarangini one is that
Chapters VII. and VIII. are not the production of Kalhana. Dr. Buhler
has satisfactorily disposed of the view of M. Troyer, but he admits
the correctness of a statement made by the; latter that Kalhana,
who brings his narrative down to the cycle year 25 or Sake 1072,
mentions in the eighth chapter events which took place eight years
later, or in the cycle year 33 . This fact, if shown to be correct, would
go directl}r to establish two things : first, that Kalhana, though he
brought down his narrative to the ecnd of the Laukika or cycle year
25, was really writing his eighth Taranga in the year 33, and second,
that he * India : What can it te
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INTRODUCTION — NOTE III. CCl introduced an

anachronism into *liis work by anticipating in the .year 25 events
which did not take place until eight years after that year. The first of
these conclusions would goto show that he did not write the history
of Jayasimha's reign for the eight years from 26 to 33, which would
be unaccountable and inconsistent with Kalhana's language; the
second would vitiate the value of his history as a reliable chronicle
even of his own time. Professor Biihler meets the charge, which, as I
have said, he admits, by saying that Kalhana did not finish his work
till the cycle year 33. But this would not remove the fault of
anachronism, and that is a fault of the greatest significance, because
Kalhana was writing then of his own times. Now there appears
available another and less objectionable way of meeting the
allegation of M. Troyer. It is this ; Kalhana does not mention in his
Vlllth book any events which took place in the cycle year 33 or eight
years after the year about the history of which he writes towards the
close of that Taranga. There is no real foundation for M, Troyer's
statement, which I find is based on a mistake made by him, owing
to his having misinterpreted the following couplet : f mprr n VIII.,
3280, 'In this manner he, when nearly thirty- three years ' of age,
was taken by the king* on the 10th day of the * M. rJ>oyer's
translation is : %I1 fut accueilli parle roi dans sa vingt " et unieme
annee, le dixieme jour du mois Djaichta (mai-juin), 1'an " trente-
trois du pays." The mistake is that the expression ^rf%f?T£§^T: has
been translated by "the thirty-third year of the country." It is
needless to prove that this is wrong. Couf. : Pan. II. 3. 67.
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Cell GAUDAVAHO. ' month of Jyeshthain the year 21.' This

refers to the taking of Bhoja, son of Sulkana, by order of king
Jayasimha, an event which Kalhana distinctly says took place in cycle
year 21, when Bhoja was nearly thirtythree years old, and not in
cycle year 33 or eight years after the date to which he brings down
his narrative. I have already shown that the author finished
composing his eight Tarangas of the RAjatarangini in Laukika or
cycle year 25 or just at the close of Sake1072 or in the early part of
A.D. 1151, i.e., two years after he began it in the early part of
Laukika year 24. I have already said that the pre-Karkotaka part of
the history in the Rajataranginl is not in some parts quite reliable,
being marked by a good many inadmissible periods of reigns and by
improbable and miraculous events. That does not prove that the
whole of the period before A.D. 596 is fabulous or even suspicious.
Far from it. The kings appear to be all historical , and the more we
approach the commencement of the Karkotakas, the more reliable
appear the facts and dates given by Kalhana. And as yet no facts
have been so undeniably established in regard to the dates and
names of the kings of the early dynasties as to clearly pro ve the
incorrectness of the accounts contained in the Rajataranginl. Even
the date of Kanishka, one of the fifty-two kings, whose historical
character has been established by coins and inscriptions, is still
unsettled, and varies by centuries. The identity of Aspka, also one of
the fiftytwo kings, if he be a historical reality in Kashmir, with the
Buddhist emperor of that name who reigned at Pataliputra in
Magadha, though very probable, is not free from doubts. As yet no
inscriptions, coins, chro 
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INTRODUCTION — NOTE III. CClii nicies, or independent

evidence of any other kind has been found, which has proved
beyond doubt that any given part of Kalhana's narrative, though
probably containing many faults, is wrong. As yet the unusually long
reigns of several of the early kings, the perhaps too great antiquity
assigned to some of them, and some flagrant improbabilities, merely
raise our suspicions that the early dynasties are not quite correctly
given in all their details. Nor has any proof been adduced to show
that those faults are the result of Kalhana's handling of the previous
contemporary chronicles and other materials which he used, and not
of the latter. Suspicions regarding the duration of the reign or the
date of one or more kings in a given list such as that of the first
three groups of Kalhana, ought not to vitiate the whole list, when we
know that Kalhana used older chronicles by contempomry writers
and other materials of an equally reliable character in making out his
lists, and when it is highly probable that there were separate records
or other evidence bearing upon separate kings. Even though ho may
have fixed by guess or computation the dates of one or more
obscure kings about whom either there was no detailed history or he
was uncertain, the rest of the list must be presumed to have been
fixed by means of the previous chronicles, inscriptions, coins, &c.
Unless we knew that the whole list was fixed by guess or
computation, it would not be right to suspect the whole of the list.
So far as independent evidence has come to light, it has rather gone
to prove that Kalhana in his earlier chapters has faithfully handed
down the ancient traditions of Kashmir, and that in his later chapters
he has
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CC1V GAUDAVAHO. given dates which are shown to be

correct. Thus, the Chinese pilgrim Hiouen-Thsang translates legends
about the desiccation of the lakes of Kashmir and the first
colonization of that country, which closely agree with those given by
Kalhana. Again, Kalhana states ihat the Karkotakas had come into
power in succession to the Gonardas in A.D. 596, which is confirmed
by Hiouen-Thsang who says that when he visited Kashmir (according
to General Cunningham circa 631 A.D.) the Ki>li-to, a nickname by
which the Karkotakas were known, had already come into power
after many centuries of rule by the philo-Buddhistic Gonardas, and
that one of them was on the throne, who had not much faith in
Buddhism. As Professor Biihler truly says, " it may seem ** scarcely
credible that a book which has engaged the •' attention of so, man/
Sanskritists, and of some of the " first rank, is, after all the labour
expended, not in a "satisfactory condition, and that its explanation *'
leaves a great deal to desire/' To this I would only add that at least
until the text of that admittedly valuable work — the only historical
compilation of any pretensions that has yet come to light — has
been carefully edited and restored to its original purity by competent
and patient hands, it will be only reasonable to expect that, after all
that some great scholars have written about it, we should 'suspend
our judgment as to its historical value, even \\i regard to its earlier
parts, and though, failing independent evidence* we might hesitate
to accept its correctness in some parts, and even ignore certain
stories as merely mythical, we should not be prepared to reject all it
says, even m
The text on this page is estimated to be only 27.18%
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INTRODUCTION - N01K IV. CCV its earlier portions, until

and unless independent evidence proves that everything contained
in it is incorrect. Probably Kalhana himself did not expect or even
desire that the same credence should be given to the whole of his
narrative in all its details in the first three Tarangas which he
expected as of right in favour of the dates and events of the
subsequent, and especially the fifth, sixth, seventh, and eighth
Tarangas. He clearly indicates now and then, that as we go back
towards antiquity the story becomes more and more traditional and
then even legendary, and that as you approach modern times it
assumes a truly historical character with as correct details as you
can expect in a work of the kind based upon materials like those
which were available to him. NOTE IV. THE DATE OF KUMAEILA-
BHATTA OR KUMARILA-SVAMf. The date of Bhavabhuti having been
fixed by the aid of the Rdjatarangini and the GaudavaJw to be in the
latter part of the seventh century, I now have the pleasure to place
before the public an important statement, which I have met with, in
an old manuscript, and which, if not shown to be incorrect, or if not
found to be a forgery, goes definitely to settle the date of the great
Mimamsa writer Kumarila-Bhatjta or Kurnarila-Svami, and thereby,
perhaps, contributes to the determination also o,f the date of the
great Sankaracharya and of those with whom the latter may be
shown to have come in contact, or whom he has mentioned in his
'writings. The statement referred to occurs in two passages in the
colophons of two of the
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CCV1 GAUJpAVAHO. ten acts of a manuscript* of

Bhavabhuti' s Mdlatimadhava. At the end of Act III occur the words:
ffrT ^^5^tc*l%*q^ JTR*cfrrrq% ^R^f:3 'here ends Act III of the
Mdlatimadhava composed by the pupil of Sri-Bhatta-Kumarila', folio
19, side 1. The colophon at the end of Act VI is as follows : 1T%
^ftfirrR^^T:, 'here ends Act VI of the Mdlatimddhava composed by
Srimat Umvekacharya, who attained to his learning through the
favour of Sri Kumarila-Svami,' folio 31, side 2. That Bhavabhuti is
meant as the author is shown by the fact, that at the end of Act X
we have the words, f i% ^r^^f^TncT Wcffanfr ^sratif :, * here
ends Act X of the Mdlatimadliava composed by Srimat Bhavabhuti',
folio 50, side 2. The colophons first mentioned occur in the body of
the manuscript, and as parts of the original writing, with matter
written before and after them ; so that it is not possible to suppose
that they may have been interpolated subsequently to the original
writing of the MS. The first leaf of the MS. is wanting. No date is
given on the last or any other page; but, judging from the
appearance of the paper, the MS. can hardly be less than between
four and five hundred years old. The paper is very old and looks
throughout made dark-brown by age, not by use, as the manuscript
does not appear to have been much used for reading, bearing no
corrections and no marks of * I am indebted for this manuscript to
my friend Mr. Mahadeva Vyankafcesa Lele, B.A , L.C.E., of IndorVj. It
contains 50 folios, with thirteen lines to the page, each line
containing thirty to thirtyfive letters. The paper is very rude and of
uneven thickness, full of patches and joints of the manufacturer. The
size of the leaves is 9 inches by 4j inches.
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INTRODUCTION — NOTE TV. CCV11 yellow paint. The first

four leaves are much worn out and torn lion; mid there, and many
others have been eaten through by moths. There is no reason to
doubt that the two colophons quoted above preserve an old
tradition, how old, and whether based in fact or not, are of course
different questions, What, however, Bhavabhuti says about himself
and his family would seem to be not inconsistent with the tradition
that Kumarila-Bhatta was one of his teachers. Both at the beginning
of the Mdlatimadliava and of the Viracliarita, we are told by him that
his ancestors were teachers ('^T'Tjr?:) of their sfikha of the Veda
(Taittiriya), so learned and pure as to be fit to purify by their
association those requiring purification *)* the keepers of the five
sacrificial fires , faithful to their religious vows (^Tcfl":), performers
of sacrifices (flftpftf^Rti lit. ' drinkers of Soma'), and students of
theology; and that his grandfather Bhatta Gopala had performed the
sacrifice called Vajapeya. This description would favour a supposition
that they must have been versed in the Mimamsa; and if so, it is
only natural to suppose, that Bhavabhuti learned that sastra on
account of the partiality of his immediate ancestors for the Veda, the
vedic rites, and, perhaps, also the Mimamsa. For, the Mimamsa
Sastra has always been believed to be necessary for an orthodox
exegesis of the Vedas. It is true that, though Manu III. 183, 184fgg.
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CCVlll GAUDAVAHO. Bhavabhuti tells us what he had

learned*— the Veda, the Upanishads, the Sankhya, the Yoga, and
the Alankara — he does not mention a knowledge of the Mimamsa
Sastra among his acquirements. But this omission on his part is very
welcome to us, indeed, as rather proving, that the tradition that he
was a pupil of Kumar -ila-Bhatta was not invented by his admirers
from his being known to be learned in the Mimamsa, but was
independent of any such spurious origin. Nor can it be supposed,
that the tradition 'might have arisen from the famous description of
his ancestors given by himself, as there is no mention therein, that
they were learned in the Mimamsa, their having^had any knowledge
thereof being merely a matter of supposition which is not even quite
necessary, though only reasonable. If the date of Kumarila-Bhatta
may be taken to be fixed by the statements under consideration, he
may be placed somewhere about the middle of the seventh century.
For, we have already seen, that Vakpati knew and admired
Bhavabhuti when he was young, and regarded him as his teacher or
leader. If we place Yasovarma's reign between A.D. 675 and 710,
Vakpati would have lived, we will say, from A.D. 660 to 720.
Bhavabhuti, who was patronized by Yasovarma, and was older than
Vakpati, would then be assigned to, we will say, from A.D. 620 to
685. In that case Kumarila may 'be placed between, say, A.D. 590
and 650. For, to have been a teacher of ft w> ^r%? 3°rf ^2-% | . I
Malat. I. 7.
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