bad breath

Halitosis, or most commonly bad breath are terms used to describe noticeably unpleasant odors exhaled in breathing – whether the smell is from an oral source or not. Halitosis has a significant impact – personally and socially – on those who suffer from it or believe they do (halitophobia), and is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.

General

In most cases (85–90%), bad breath originates in the mouth itself. The intensity of bad breath differs during the day, due to eating certain foods (such as garlic, onions, meat, fish, and cheese), obesity, smoking, and alcohol consumption. Because the mouth is exposed to less oxygen and is inactive during the night, the odor is usually worse upon awakening ("morning breath"). Bad breath may be transient, often disappearing following eating, brushing one's teeth, flossing, or rinsing with specialised mouthwash.

Bad breath may also be persistent (chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees. It can negatively affect the individual's personal, social, and business relationships, leading to poor self-esteem and increased stress.

Origins

Mouth

There are over 600 types of bacteria found in the average mouth. Several dozen of these can produce high levels of foul odors when incubated in the laboratory. The odors are produced mainly due to the anaerobic breakdown of proteins into individual amino acids, followed by the further breakdown of certain amino acids to produce detectable foul gases. For example, the breakdown of cysteine and methionine produce hydrogen sulfide and methyl mercaptan respectively. Volatile sulfur compounds have been shown to be statistically associated with oral malodor levels, and usually decrease following successful treatment.

Other parts of the mouth may also contribute to the overall odor, but are not as common as the back of the tongue. These locations are, in descending prevalence order: inter-dental and sub-gingival niches, faulty dental work, food-impaction areas in-between the teeth, abscesses and unclean dentures.

Tongue

The most common location for mouth-related halitosis is the tongue. Large quantities of naturally-occurring bacteria are often found on the posterior dorsum of the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and bacterial populations can thrive on remnants of food deposits, dead epithelial cells and postnasal drip. The convoluted microbial structure of the tongue dorsum provides an ideal habitat for anaerobic bacteria, which flourish under a continually-forming tongue coating of food debris, dead cells, postnasal drip and overlying bacteria, living and dead. When left on the tongue, the anaerobic respiration of such bacteria can yield either the putrescent smell of indole, skatole, polyamines, or the "rotten egg" smell of volatile sulfur compounds (VSCs) such as hydrogen sulfide, methyl mercaptan, Allyl methyl sulfide and dimethyl sulfide.

Cleaning the tongue

The most widely-known reason to clean the tongue is for the control of bad breath. Methods used against bad breath, such as mints, mouth sprays, mouthwash or gum, may only temporarily mask the odors created by the bacteria on the tongue, but can not cure bad breath because they do not remove the source of the bad breath. In order to prevent the production of the sulfur-containing compounds mentioned above, the bacteria on the tongue must be removed; as must the decaying food debris present on the rear areas of the tongue. Most people who clean their tongue use a tongue cleaner (tongue scraper), or a toothbrush. Ergonomic, specially designed tongue cleaners are a lot more effective (collecting and removing the bacterial coating) than toothbrushes (which merely spread the bacterial accumulations on the tongue and in the mouth).

Gum disease

There is some controversy over the role of periodontal diseases in causing bad breath. Whereas bacteria growing below the gumline (subgingival dental plaque) have a foul smell upon removal, several studies reported no statistical correlation between malodor and periodontal parameters.

Nose

The second major source of bad breath is the nose. In this instance, the air exiting the nostrils has a pungent odor which differs from the oral odor. Nasal odor may be due to sinus infections or foreign bodies.

Tonsils

Putrefaction from the tonsils is generally considered a minor cause of bad breath, contributing to some 3-5% of cases. Approximately 7% of the population suffer from small bits of calcified matter in tonsillar crypts called tonsilloliths that smell extremely foul when released and can cause bad breath.

Stomach

The stomach is considered by most researchers as a very uncommon source of bad breath (except in belching). The esophagus is a closed and collapsed tube, and continuous flow (as opposed to a simple burp) of gas or putrid substances from the stomach indicates a health problem - such as reflux serious enough to be bringing up stomach contents or a fistula between the stomach and the esophagus - which will demonstrate more serious manifestations than just foul odor.

In the case of allyl methyl sulfide, odor does come from the stomach since it does not get metabolized there.

Systemic diseases

There are a few systemic (non-oral) medical conditions which may cause foul breath odor, but these are extremely infrequent in the general population. Such conditions are:

1. Fetor hepaticus: an example of a rare type of bad breath caused by chronic liver failure.
2. Lower respiratory tract infections (bronchial and lung infections).
3. Renal infections and renal failure.
4. Carcinoma.
5. Trimethylaminuria ("fish odor syndrome").
6. Diabetes mellitus.
7. Metabolic dysfunction.

Individuals afflicted by the above conditions often show additional, more diagnostically conclusive symptoms than bad breath. People troubled by bad breath should not conclude that they suffer from these conditions or disease.

Diagnosis

Self diagnosis and home diagnosis

Scientists have long thought that smelling one's own breath odor is often difficult due to acclimatization, although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis isn't easy because of preconceived notions of how bad we think it should be. Some people assume that they have bad breath because of bad taste (metallic, sour, fecal, etc), however bad taste is considered a poor indicator.

For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend. If the confidant confirms that there is a breath problem, he or she can help determine whether it is coming from the mouth or the nose, and whether a particular treatment is effective or not.

One popular home method to determine the presence of bad breath is to lick the back of the wrist, let the saliva dry for a minute or two, and smell the result. This test results in overestimation, as concluded from research, and should be avoided. A better way would be to lightly scrape the posterior back of the tongue with a plastic disposable spoon and to smell the drying residue. A spouse, family member, or close friend may be willing to smell one's breath and provide honest feedback. Home tests are now available which use a chemical reaction to test for the presence of polyamines and sulfur compounds on tongue swabs, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing may be necessary.

Professional diagnosis

If bad breath is persistent, and all other medical and dental factors have been ruled out, specialised testing and treatment is required. Hundreds of dental offices and commercial breath clinics now claim to diagnose and treat bad breath. They often use some of several laboratorial methods for diagnosis of bad breath:

1. Halimeter: a portable sulfide monitor used to test for levels of sulfur emissions (specifically, hydrogen sulfide) in the mouth air. When used properly this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such as mercaptan) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.
2. Gas chromatography: portable machines, such as the OralChroma, are currently being introduced. This technology is specifically designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air (hydrogen sulfide, methyl mercaptan, and dimethyl sulfide). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.
3. BANA test: this test is directed to find the salivary levels of an enzyme indicating the presence of certain halitosis-related bacteria.
4. β-galactosidase test: salivary levels of this enzyme were found to be correlated with oral malodor.

Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual sniffing and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six point intensity scale.

Home care and treatment

Currently, chronic halitosis is not very well understood by most physicians and dentists, so effective treatment is not always easy to find. Six strategies may be suggested:

1. Gently cleaning the tongue surface twice daily is the most effective way to keep bad breath in control; that can be achieved using a tongue cleaner or tongue brush/scraper to wipe off the bacterial biofilm, debris and mucus. An inverted teaspoon may also do the job; a toothbrush should be avoided, as the bristles only spread the bacteria in the mouth, and grip the tongue, causing a gagging reflex. Scraping or otherwise damaging the tongue should be avoided, and scraping of the V-shaped row of taste buds found at the extreme back of the tongue should also be avoided. Brushing a small amount of antibacterial mouth rinse or tongue gel onto the tongue surface will further inhibit bacterial action.
2. Eating a healthy breakfast with rough foods helps clean the very back of the tongue.
3. Chewing gum: Since dry mouth can increase bacterial buildup and cause or worsen bad breath, chewing sugarless gum can help with the production of saliva, and thereby help to reduce bad breath. Chewing may help particularly when the mouth is dry, or when one cannot perform oral hygiene procedures after meals (especially those meals rich in protein). This aids in provision of saliva, which washes away oral bacteria, has antibacterial properties and promotes mechanical activity which helps cleanse the mouth. Some chewing gums contain special anti-odor ingredients. Chewing on fennel seeds, cinnamon sticks, mastic gum or fresh parsley are common folk remedies.
4. Gargling right before bedtime with an effective mouthwash (see below). Several types of commercial mouthwashes have been shown to reduce malodor for hours in peer-reviewed scientific studies. Mouthwashes may contain active ingredients which are inactivated by the soap present in most toothpastes. Thus it is recommended to refrain from using mouthwash directly after toothbrushing with paste (also see mouthwashes, below).
5. Maintaining proper oral hygiene, including daily tongue cleaning, brushing, flossing, and periodic visits to dentists and hygienists. Flossing is particularly important in removing rotting food debris and bacterial plaque from between the teeth, especially at the gumline. Dentures should be properly cleaned and soaked overnight in antibacterial solution (unless otherwise advised by your dentist).
6. Maintain water levels in the body by drinking several glasses of water a day.

Mouthwashes

Mouthwashes often contain antibacterial agents including cetylpyridinium chloride, chlorhexidine, zinc gluconate, essential oils, and chlorine dioxide. Zinc and chlorhexidine provide strong synergistic effect. They may also contain alcohol, which is a drying agent. Rinses in this category include Scope and Listerine.

Other solutions rely on odor eliminators like oxidizers to eliminate existing bad breath on a short-term basis. Rinses in this category include SmartMouth, Therabreath, Closys and others.

A relatively new approach for home-care of bad breath is by oil-containing mouthwashes. The use of essential oils has been studied, was found effective and is being used in several commercial mouthwashes, as well as the use of two-phase (oil:water) mouthwashes, which have been found to be effective in reducing oral malodor.

Ancient traditional remedies

According to traditional Ayurvedic medicine, chewing areca nut and betel leaf is an excellent remedy against bad breath. In South Asia it was a custom to chew areca or betel nut and betel leaf among lovers because of the breath-freshening and stimulant drug properties of the mixture. Both the nut and the leaf are mild stimulants and can be addictive with repeated use. The betel nut will also cause tooth decay and dye one's teeth bright red when chewed.

Halitophobia (delusion halitosis)

Some one quarter of the patients seeking professional advice on bad breath suffer from a highly exaggerated concern of having bad breath, known as halitophobia, delusional halitosis, or as a manifestation of Olfactory Reference Syndrome. These patients are sure that they have bad breath, although many have not asked anyone for an objective opinion. Halitophobia may severely affect the lives of some 0.5-1.0% of the adult population. Only few psychologists and health professionals have tried to come to terms with this debilitating and difficult-to-treat emotional problem.

Scientific research

In 1996, The International Society for Breath Odor Research (ISBOR) was formed to promote multidisciplinary research on all aspects of breath odors. The seventh international conference on breath odor took place in August, 2007 in Chicago, and the next conference is expected to take place in 2009 in Dortmund, Germany.

Mouthwash

Mouthwash or mouth rinse is a product used to enhance oral hygiene. Antisepticand anti-plaque mouth rinse claim to kill the bacterial plaque causing caries, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay. But, it is generally agreed that the use of mouthwash does not eliminate the need for both brushing and flossing. As per the American Dental Association, regular brushing and proper flossing are enough in most cases (In addition to regular dental check-ups).Mouth washes may also be used to help remove mucus and food particles deeper down in the throat. Alcoholic and strong flavored mouth washes may cause coughing when used for this purpose.

Listerine, an American brand of mouthwash

History

The first known reference to mouth rinsing is in the Chinese medicine, about 2700 BC, for treatment of gingivitis. Later, in theGreek and Roman periods, mouthrinsing following mechanical cleansing became common among the upper classes, and Hippocratesrecommended a mixture of salt, alum, and vinegar. The Jewish Talmud, dating back about 1800 years, suggests a cure for gum ailments containing "dough water" and olive oil.Anton van Leeuwenhoek, the famous 17th century microscopist, discovered living organisms (living, because they were motile) in deposits on the teeth (what we now call dental plaque). He also found organisms in water from the canal next to his home in Delft. He experimented with samples by adding vinegar or brandy and found that this resulted in the immediate immobilization or killing of the organisms suspended in water. Next he tried rinsing the mouth of himself and somebody else with a rather foul mouthwash containing vinegar or brandy and found that living organisms remained in the dental plaque. He concluded—correctly—that the mouthwash either did not reach, or was not present long enough, to kill the plaque organisms.That remained the state of affairs until the late 1960s when Harald Loe (at the time a professor at the Royal Dental College in Aarhus, Denmark) demonstrated that a chlorhexidine compound could prevent the build-up of dental plaque. The reason for chlorhexidine effectiveness is that it strongly adheres to surfaces in the mouth and thus remains present in effective concentrations for many hours.Since then commercial interest in mouthwashes has been intense and several newer products claim effectiveness in reducing the build-up in dental plaque and the associated severity of gingivitis (inflammation of the gums), in addition to fighting bad breath. Many of these solutions aim to control the Volatile Sulfur Compound (VSC)-creating anaerobic bacteria that live in the mouth and excrete substances that lead to bad breath and unpleasant mouth taste.



Usage

Common use involves rinsing the mouth with about 20ml (2/3 fl oz) of mouthwash two times a day after brushing. The wash is typically swished or gargled for about half a minute and then spat out. In some brands, the expectorate is stained, so that one can see the bacteria and debris. It is probably advisable to use mouthwash at least an hour after brushing with toothpaste when the toothpaste contains sodium lauryl sulfate, since the anionic compounds in the SLS toothpaste can deactivate cationic agents present in the mouthrinse. When using mouthwash just remember the 4 S's "swig", "swish", "spit" and "smile".



Active ingredients

OTC mouthwash containing chlorhexidine fromMexico.Active ingredients in commercial brands of mouthwash can include thymol, eucalyptol, hexetidine, methyl salicylate,menthol, chlorhexidine gluconate, benzalkonium chloride, cetylpyridinium chloride, methylparaben, hydrogen peroxide, domiphen bromide and sometimes fluoride, enzymes and calcium. Ingredients also include water, sweeteners such as sorbitol, sucralose, sodium saccharine, and xylitol (which doubles as a bacterial inhibitor).Sometimes a significant amount of alcohol (up to 27% vol) is added, as a carrier for the flavor, to provide "bite", and to contribute an antibacterial effect. Because of the alcohol content, it is possible to fail a breathalyzer test after rinsing; in addition, alcohol is a drying agent and may worsen chronic bad breath. Furthermore, it is possible for alcoholics to abuse mouthwash Recently, some assumptions were made of a possible carcinogenic character of alcohol used in mouthrinses, but no clear evidence was found. Commercial mouthwashes usually contain a preservative such as sodium benzoate to preserve freshness once the container has been opened. Many newer brands are alcohol-free and contain odor-elimination agents such as oxidizers, as well as odor-preventing agents such aszinc ion to keep future bad breath from developing.

OTC mouthwash containing chlorhexidine fromMexico.

Alternative Mouthwash Ingredients

A salt mouthwash is a home treatment for mouth infections and/or injuries, or post extraction, and is made by dissolving a teaspoon of salt in a cup of warm water. However, such mouthwashes have no effect in killing germs.Recently, the use of herbal mouthwashes such as persica is increasing, due to the perceived discoloration effects and unpleasant taste of Chlorhexidine. Research has also indicated that sesame and sunflower oils as cheap alternatives compared to chlorhexidine.Other products like hydrogen peroxide have been tried out as stand-alone and in combination with chlorhexidine, due to some inconsistent results regarding its usefulness.Another study has demonstrated that daily use of an alum-containing mouthrinse was safe and produced a significant effect on plaque that supplemented the benefits of daily toothbrushing.However, many studies acknowledge that Chlorhexidine remains the most effective mouthwash when used on an already clean tooth surface or immeadiately after surgery. As chlorhexidine has difficulty in penetrating plaque biofilm, other mouthwashes may be more effective where pre-existing plaque is present.


Health Risks

In January 2009 a report published in the Dental Journal of Australia concluded there is "sufficient evidence" that "alcohol-containing mouthwashes contribute to the increased risk of development of oral cancer". However, this claim has been disputed by Yinka Ebo ofCancer Research UK, concluding that "there is still not enough evidence to suggest that using mouthwash that contains alcohol will increase the risk of mouth cancer"


List of mouthwash brands

• Astring-O-Sol
• Scope (mouthwash)
• Dentyl pH
• Sarakan
• Oral-B
• Colgate
• Corsodyl
• Listerine

Geriatric dentistry

Geriatric dentistry or gerodontics is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other health care professionals.

Temporomandibular joint disorder

Temporomandibular joint

Temporomandibular joint disorder (TMJD, TMJ or TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry, neurology, physical therapy, and psychology — there are a variety of treatment approaches.

The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, and neoplasia.

Signs and symptoms

Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex. Often the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder. Temporomandibular joint disorder is sometimes mistaken for pain arising from impacted third molars.

Muscles

TMJ diagram

Disorders of the muscles of the temporomandibular joint are the most common complaints by TMD patients. The two major observations concerning the muscles are pain and dysfunction. The dysfunction can present as trismus or limitation of jaw movement ranging from minor to severe. In milder cases, the only representation may be joint sound such as clicking or popping. These symptoms of TMD are often caused by overusage of the muscles of mastication. Common causes include chewing gum continuously, biting habits (fingernails and pencils), grinding habits, and clenching habits.

Most cases of TMJ, however, are not so simple. Deep-space infections with resulting trismus or neoplams about the joint may mimic TMJ dysfunction. Muscle pain can sometimes be associated with trigger points in muscle tissue. These trigger points can be localized by digital palpation, both intraorally and extraorally. This is known as Myofascial pain syndrome.

Any dysfunction of the muscles may cause the teeth to occlude (bite) with each other incorrectly; if teeth are traumatized by this, they may become sensitive, demonstrating one of the many interplays between muscle, joint, and tooth.

Temporomandibular joints

This is arguably the most complex set of joints in the human body. Unlike typical finger or vertebral junctions, each TMJ actually has two joints, which allow it to both rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of it. Clicking is common, as are popping motions and deviations in the movements of the joint. It is considered a TMJ disorder when pain is involved.

In a healthy joint, the surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues. When receptors from one of these areas are triggered, the pain causes a reflex to limit the mandible's movement. Furthermore, inflammation of the joints can cause constant pain, even without movement of the jaw.

Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain. The pain may be referred in around half of all patients and experienced as otalgia (earache). Conversely, TMD is an important possible cause of secondary otalgia. Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus, as well as atypical facial pain. Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.

The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc. The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.

Teeth

Disorders of the teeth can contribute to TMJ disfunction. Impaired tooth mobility and tooth loss can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Maybe the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle.

Precipitating factors

There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:

Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:

1. Trauma
2. Repetitive unconscious jaw movements called bruxing.
3. Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
4. Jaw thrusting (causing unusual speech and chewing habits).
5. Excessive gum chewing or nail biting.
6. Size of foods eaten.
7. Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
8. Myofascial pain dysfunction syndrome

Treatment

Restoration of the occlusal surfaces of the teeth

If the occlusal surfaces of the teeth or the supporting structures have been damaged due to dental neglect, periodontal diseases or trauma, the proper occlusion should be restored.

Pain relief

While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neuralgic in nature, which often does not respond well to these drugs.

An alternative approach is for pain modification, for which off-label use of low-doses of Tricyclic antidepressant that have anti-muscarinic properties (e.g. Amitriptyline or the less sedative Nortriptyline) generally prove more effective.

Long-term approach

It is suggested that before the attending dentist commences any plan or approach utilizing medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.

An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and results in jaw pain. Palpation of these muscles will cause a painful response.

Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A flat-plane full-coverage oral appliance, e.g. a non-repositioning stabilization splint, often is helpful to control bruxism and take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may then prove helpful. This method of treatment is often referred to as "splint therapy."

According to the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), TMJ treatments should be reversible whenever possible. That means that the treatment should not cause permanent changes to the jaw or teeth. Examples of reversible treatments are:

• Over-the-counter pain medications, used according to manufacturers’ instructions.
• Prescription medications prescribed by a healthcare provider.
• Gentle jaw stretching and relaxation exercises you can do at home. Your healthcare provider can recommend exercises for your particular condition, if appropriate.
• Feldenkrais TMJ Program, uses a unique understanding of human neurology to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJ symptoms.
• Stabilization splint (biteplate, nightguard) is the most widely used treatment for TMJ and jaw muscle problems; however, the actual effectiveness of these splints is unclear. If an oral splint is recommended, it should be used only for a short time and should not cause permanent changes in the bite. If a splint causes or increases pain, stop using it and tell your healthcare provider. Avoid using over-the-counter mouthguards for TMJ treatment. If a splint is not properly fitted, the teeth may shift and worsen the condition.
• Mandibular Repositioning Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night.

What may be concluded is that there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:

• Manual adjustment of the bite by grinding the teeth
• Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
• Reconstructive dentistry
• Orthodontics
• Arthrocentesis (joint irrigation)
• Surgical repositoning of jaws to correct congenital jaw malformations such as prognathism and retrognathia
• Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)

Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have changed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery as a last resort. Certainly a focus on other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining oral-facial pain specialist, oral surgeon or health professional. One option for oral surgery, is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis. In some cases, this will reduce the inflammatory process.

Dental implant

X-Ray picture of two dental implants inserted into the posterior mandible.

A dental implant is an artificial tooth root replacement and is used in prosthetic dentistry to support restorations that resemble a tooth or group of teeth. There are several types of dental implants. The major classifications are divided into osseointegrated implant and the fibrointegrated implant. Earlier implants, such as the subperiosteal implant and the blade implant were usually fibrointegrated. The most widely accepted and successful implant today is the osseointegrated implant, based on the discovery by Swedish Professor Per-Ingvar Brånemark that titanium can be successfully fused into bone when osteoblasts grow on and into the rough surface of the implanted titanium. This forms a structural and functional connection between the living bone and the implant. A variation on the implant procedure is the implant-supported bridge, or implant-supported denture.

History

The Mayan civilization has been shown to have used the earliest known examples of endosseous implants (implants embedded into bone), dating back over 1,350 years before Per-Ingvar Brånemark started working with titanium. While excavating Mayan burial sites in Honduras in 1931, archaeologists found a fragment of mandible of Mayan origin, dating from about 600 AD. This mandible, which is considered to be that of a woman in her twenties, had three tooth-shaped pieces of shell placed into the sockets of three missing lower incisor teeth. For forty years the archaeological world considered that these shells were placed after death in a manner also observed in the ancient Egyptians. However, in 1970 a Brazilian dental academic, Professor Amadeo Bobbio studied the mandibular specimen and took a series of radiographs. He noted compact bone formation around two of the implants which led him to conclude that the implants were placed during life.

In the 1950s research was being conducted at Cambridge University in England to study blood flow in vivo. These workers devised a method of constructing a chamber of titanium which was then embedded into the soft tissue of the ears of rabbits. In 1952 the Swedish orthopaedic surgeon, P I Brånemark, was interested in studying bone healing and regeneration, and adopted the Cambridge designed ‘rabbit ear chamber’ for use in the rabbit femur. Following several months of study he attempted to retrieve these expensive chambers from the rabbits and found that he was unable to remove them. Per Brånemark observed that bone had grown into such close proximity with the titanium that it effectively adhered to the metal. Brånemark carried out many further studies into this phenomenon, using both animal and human subjects, which all confirmed this unique property of titanium.

Although he had originally considered that the first work should centre on knee and hip surgery, Brånemark finally decided that the mouth was more accessible for continued clinical observations and the high rate of edentulism in the general population offered more subjects for widespread study. He termed the clinically observed adherence of bone with titanium as ‘osseointegration’. In 1965 Brånemark, who was by then the Professor of Anatomy at Gothenburg University in Sweden, placed the first titanium dental implant into a human volunteer, a Swede named Gösta Larsson.

Contemporaneous independent research in the United States by Stevens and Alexander led to a 1969 US patent filing for titanium dental implants.

Over the next fourteen years Brånemark published many studies on the use of titanium in dental implantology until in 1978 he entered into a commercial partnership with the Swedish defense company, Bofors AB for the development and marketing of his dental implants. With Bofors (later to become Nobel Industries) as the parent company, Nobelpharma AB (later to be renamed Nobel Biocare) was founded in 1981 to focus on dental implantology. To the present day over 7 million Brånemark System implants have now been placed and hundreds of other companies produce dental implants. The majority of dental implants currently available are shaped like small screws, with either tapered or parallel sides. They can be placed at the same time as a tooth is removed by engaging with the bone of the socket wall and sometimes also with the bone beyond the tip of the socket. Current evidence suggests that implants placed straight into an extraction socket have comparable success rates to those placed into healed bone. The success rate and radiographic results of immediate restorations of dental implants placed in fresh extraction sockets (the temporary crowns placed at the same time) have been shown to be comparable to those obtained with delayed loading (the crowns placed weeks or months later) in carefully selected cases

Some current research in dental implantology is focusing on the use of ceramic materials such as zirconia (ZrO2) in the manufacture of dental implants. Zirconia is the dioxide of zirconium, a metal close to titanium in the periodic table and with similar biocompatability properties. Although generally the same shape as titanium implants zirconia, which has been used successfully for orthopaedic surgery for a number of years, has the advantage of being more cosmetically aesthetic owing to its bright tooth-like colour. However, long-term clinical data is necessary before one-piece ZrO₂ implants can be recommended for daily practice.

Composition of Implants

A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface. The majority of dental implants made out of commercially pure titanium, which is available in 4 grades depending upon the amount of carbon and iron contained. More recently grade 5 titanium has increased in use. Grade 5 titanium, Titanium 6AL-4V, (signifying the Titanium alloy containing 6% Aluminium and 4% Vanadium alloy) is believed to offer similar osseointegration levels as commercially pure titanium. Ti-6Al-4V alloy offers better tensile strength and fracture resistance. Today most implants are still made out of commercially pure titanium (grades 1 to 4) but some implant systems (Endopore and NanoTite) are fabricated out of the Ti-6Al-4V alloy Implant surfaces may be modified either by plasma spraying, anodizing, etching or sandblasting to increase the surface area and the integration potential of the implant.

Training

Implant surgery may be performed as an outpatient under general anesthesia, oral conscious sedation, nitrous oxide sedation, intravenous sedation or under local anesthesia by trained and certified clinicians including general dentists, oral surgeons, prosthodontists, and periodontists.

The legal training requirements for dentists who carry out implant treatment differ from country to country. In the UK implant dentistry is considered by the General Dental Council to be a postgraduate sphere of dentistry. In other words it is not sufficiently covered during the teaching of the university dental degree course and dentists wishing to practice in dental implantology legally need to undergo additional formal postgraduate training. The General Dental Council has published strict guidelines on the training required for a dentist to be able to place dental implants in general dental practice. UK dentists need to complete a competency assessed postgraduate extended learning program such as the UK Implantology Year Course before providing implant dentistry to patients.

The degree to which both graduate and post-graduate dentists receive training in the surgical placement of implants varies from country to country but it seems likely that lack of formal training will lead to higher complication rates.

Surgical procedure

Surgical planning

Prior to commencement of surgery, careful and detailed planning is required to indentify vital structures such as the inferior alveolar nerve or the sinus and to properly orientate the implants for the most predictable outcome. Two dimensional radiographs, such as orthopantomographs or periapicals are taken prior to the surgery. In some instances, a CT scan will also be obtained and specialized 3D CAD/CAM computer programs used to plan case.

Whether CT-guided or manual, a 'stent' may sometimes be required to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed. The surgical stent may be produced using stereolithography following computerized planning of a case from the CT scan.

Basic procedure

In its most basic form the placement of an osseointegrated implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed to prevent burning or pressure necrosis of the bone. After a variable amount of time to allow the bone to grow onto the surface of the implant (osseointegration) a tooth or teeth can be placed on the implant. The amount of time required to place an implant will vary depending on the experience of the practitioner and difficulty of the individual situation.

Detail procedure

At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular the inferior alveolar nerve or IAN and the mental foramen within the mandible). Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.

Surgical incisions

Traditionally, an incision is made over the crest of the site where the implant is to be placed. This is referred to as a 'flap'. Some systems allow for 'flapless' surgery where a piece of mucosa is punched-out from over the implant site. Proponents of 'flapless' surgery believe that it decreases recovery time while its detractors believe it increases complication rates because the edge of bone cannot be visualized. Because of these visualization problems flapless surgery is often carried out using a surgical guide constructed following computerized 3D planning of a pre-operative CT scan.

Healing time

The amount of time required for an implant to become osseointegrated is a hotly debated topic. Consequently the amount of time that practitioners allow the implant to heal before placing a restoration on it varies widely. In general, practitioners allow 2–6 months for healing but preliminary studies show that early loading of implant may not increase early or long term complications.

One-stage, Two-stage surgery

When an implant is placed either a healing abutment, which comes through the mucosa is placed or a 'cover screw' which is flush with the surface of the dental implant is placed. When a cover screw is placed the mucosa covers the implant while it integrates then a second surgery is completed to place the healing abutment.

Two-stage surgery is sometimes chosen when a concurrent bone graft is placed or surgery on the mucosa may be required for esthetic reasons. Some implants are one piece so that no healing abutment is required.

In carefully selected cases patients can be implanted and restored in a single surgery, in a procedure labeled "Immediate Loading". In such cases a provisional prosthetic tooth or crown is shaped to avoid the force of the bite transferring to the implant while it integrates with the bone.

Surgical timing

There are different approaches to place dental implants after tooth extraction. The approaches are:

1. Immediate post-extraction implant placement.
2. Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
3. Late implantation (3 months or more after tooth extraction).

According to the timing of loading of dental implants, the procedure of loading could be classified into:

1. Immediate loading procedure.
2. Early loading (1 week to 12 weeks).
3. Delayed loading (over 3 months)

Immediate placement

An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable. This can cut months off the treatment time and in some cases a prosthetic tooth can be attached to the implants at the same time as the surgery to place the dental implants.

Most data suggests that when placed into single rooted tooth sites with healthy bone and mucosa around them, the success rates are comparable to that of delayed procedures with no additional complications.

Use of CT scanning

When computed tomography, also called cone beam computed tomography or CBCT (3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures, the zone of safety may be reduced to 1 mm through the use of computer-aided design and production of a surgical drilling and angulation guide.

Complementary procedures

Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as a periodontist, prosthodontist, or oral surgeon thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance. This results in more volume for a better quality bone site for the implantation. Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the precision diagnostic guidance afforded by a 3D CBCT X-ray, as in the case of posterior mandibular implants discussed earlier.

Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height—which is very difficult to achieve—is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth.

Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or better cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.

A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bone-like substances (calcium sulfate with names like Regeneform; and hydroxyapatite or HA, which is the primary form of calcium found in bone). The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups. Alternatively the bone intended to support the implant can be split and widened with the implant placed between the two havles like a sandwich. This is referred to as a 'ridge split' procedure..

Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity. Then the mucosa is carefully sutured over the site. Together with a course of systemic antibiotics and topical antibacterial mouth rinses, the graft site is allowed to heal (several months).

The clinician typically takes a new radiograph to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predicts success in the third dimension; depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam radiograph may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same radiographic data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.

Considerations

For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases careful consideration must be given to the final functional aspects of the restoration, such as assessing the forces which will be placed on the implant. Implant loading from chewing and parafunction (abnormal grinding or clenching habits) can exceed the biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.

The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the periodontist, endodontist, oral surgeon, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan.

Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereolithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis' occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as 'SimPlant' (simulated implant) or 'NobelGuide' use the digital data from a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab for production of a precision in-mouth drilling guide.

Success rates

Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and also to the patient's oral hygiene. The general consensus of opinion is that implants carry a success rate of around 95% One of the most important factors that determine implant success is the achievement and maintenance of implant stability. The stability is presented as an ISQ (Implant Stability Quotient) value.

Failure

Failure of a dental implant is often related to failure to osseointegrate correctly. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (around the implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2mm a year after.

Dental implants are not susceptible to dental caries but they can develop a condition called peri-implantitis. This is an inflammatory condition of the mucosa and/or bone around the implant which may result in bone loss and eventual loss of the implant. The condition is usually, but not always, associated with a chronic infection. Peri-implantitis is more likely to occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases where the mucosa around the implant is thin.

Currently there is no universal agreement on the best treatment for peri-implantitis. The condition and its causes is still poorly understood.

Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

Failure may also occur independently of the causes outlined above. Implants like any other object suffers from wear and tear. If the implants in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up. This is a very rare occurrence, however possible. The only way to minimize the risk of this happening is to visit your dentist for regular reviews.

In the majority of cases where an implant fails to integrate with the bone and is rejected by the body the cause is unknown. This may occur in around 5% of cases. To this day we still do not know why bone will integrate with titanium dental implants and why it does not reject the material as a 'foreign body'. Many theories have been postulated over the last five decades. A recent theory argues that rather than being an active biological tissue response, the integration of bone with an implant is the lack of a negative tissue response. In other word for unknown reasons the usual response of the body to reject foreign objects implanted into it does not function correctly with titanium implants. It has further been postulated that an implant rejection occurs in patients whose bone tissues actually react as they naturally should with the 'foreign body' and reject the implant in the same manner that would occur with most other implanted materials.

Contraindications

There are few absolute contraindications to implant dentistry. However there are some systemic, behavioral and anatomic considerations that should be assessed.

Particularly for mandibular (lower jaw) implants, in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.

Uncontrolled type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.

There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.

The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may sometimes be advised to stop the administration prior to implant surgery, then resume several months later. However, current evidence suggests that this protocol may not be necessary. As of January, 2008, an oral bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms." (JOMS, Volume 66, Issue 2, Ppgs 223-230).

The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health," (JADA, Vol. 137, page 1048, July 2006.) In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June, 2006. The overview may be read online at ada.org but it has now been superseded by a huge study—encompassing over 700,000 cases—entitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants. (JADA, January 2008, 139:23-30).

Bruxism (tooth clenching or grinding) is another consideration which may reduce the prognosis for treatment. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient. Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night.

Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chin—usually noticed after surgical anesthesia wears off—is another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

The market

In the United States and the United Kingdom, there is no exclusive specialty in 'implantology'.

Any practitioner who carries out implant treatment, whether in the surgical insertion or the final provision of the prosthesis, must be adequately trained. Legal training requirements differ between countries.

In 2008, in the UK the General Dental Council (GDC) laid down strict training requirements for dentists involved in dental implantology. Any dentist in the UK who wishes to train in the field of dental implantology must take part in an extended learning program which covers a detailed theory syllabus, as approved by the GDC, in addition to formal supervised surgical training and mentoring. Dentists must not take part in implant dentistry in the UK until they have been approved by the training provider as having passed a formal competency assessment. Failure to comply with the GDC regulations may result in a dentist being removed from the Dental Register and hence losing the right to practice dentistry in the UK.

Cosmetic dentistry

Cosmetic dentistry, is comprehensive oral care that combines art and science to optimally improve dental health, aesthetics and function.

Treatments

See the page for Prosthodontics for more information.

Today's common cosmetic dental treatment options include:

• Whitening, or "tooth bleaching", is the most common cosmetic dental procedure. While many whitening options are now available, dentist-supervised treatments remain the recommended procedures for lightening discolored teeth.

• Enamel shaping removes parts of the contouring enamel to improve the appearance of the tooth. It may be used to correct a very small chip. The removed enamel is irreplaceable, and may sometimes expose dentin. It is also known as enameloplasty, odontoplasty, recontouring, reshaping, slenderizing and stripping.

• Contouring, also known as tooth reshaping, is one of few instant treatments now available in cosmetic dentistry. Dental reshaping and contouring is a procedure to correct crooked teeth, chipped teeth, cracked teeth or even overlapping teeth in just one session. The dental contouring procedure can even be a substitute for braces under certain circumstances. It is also a procedure of subtle changes. A few millimeters of reduction and a few millimeters of tooth-colored laminate is involved. Tooth reshaping, or dental contouring, is commonly used to alter the length, shape or position of teeth.

• Bonding is a process in which an enamel-like dental composite material is applied to a tooth's surface, sculpted into shape, hardened and then polished.

• Dental bridges are false teeth, known as a pontics, which are fused between two porcelain crowns to fill in the area left by a missing tooth. The two crowns holding it in place that are attached onto your teeth on each side of the false tooth. This is known as a fixed bridge. This procedure is used to replace one or more missing teeth. Fixed bridges cannot be taken out of your mouth as you might do with removable partial dentures. In areas of your mouth that are under less stress, such as your front teeth, a cantilever bridge may be used. Cantilever bridges are used when there are teeth on only one side of the open space. Bridges can reduce your risk of gum disease, help correct some bite issues and even improve your speech. Bridges require your commitment to serious oral hygiene, but will last as many ten years or more.

• Veneers are ultra-thin, custom-made laminates that are bonded directly to the teeth. They are an option for closing gaps or disguising discolored teeth that do not respond well to whitening procedures.

• Gum lift is a cosmetic dental procedure that raises and sculpts the gum line. The procedure involves reshaping the tissue and/or underlying bones to create the appearance of longer or more symmetrical teeth.

Materials

In the past, dental fillings and other tooth restorations were made of gold, amalgam and other metals -- some of which were veneered with porcelain. Now, dental work can be made entirely of porcelain or composite materials that more closely mimic the appearance of natural tooth structure. These tooth colored materials are bonded to the underlying tooth structure with resin adhesives. Unlike silver fillings (amalgams) they are entirely free of mercury. Many dentists offer procedures to be cosmetic and because their patients prefer natural looking teeth.

Conservative Dentistry

Conservative dentistry is a branch of dentistry, which is concerned, with the conservation of teeth in the mouth. It consists of the sub-specialties of cariology, operative dentistry, and endodontics. A dentist usually specializes in conservative dentistry or can individually specialize in any of its three sub specialties.

Cariology: The discipline Cariology includes studies of all aspects of the tooth decay its cause, its prevention and its treatment - on the tooth surface.

Operative dentistry: Operative dentistry is that branch which deals with the diagnoses and treatment of structural defects in teeth which are the result of, or which predispose a tooth to, disease. The primary objective is to restores proper tooth shape and structure, function, esthetics and its harmonious relationships with surrounding tissues while preserving pulpal health. The field of operative dentistry is recognized as the core of general dental practice.

Endodontics: Endodontics is the branch of dentistry that deals with diseases of the tooth's pulp. Endodontics simply means” within the tooth” .Removal of the diseased pulp from the root canal and its subsequent filling is called endodontic treatment, which is often referred to as root-canal treatment or root canal therapy. The common treatment procedures carried out by a dentist who specializes in conservative dentistry are:

1. Fillings
a. Amalgam
b. Composite
2. Inlays & Onlays
3. Jacket & full crowns
4. Veneers
5. Root Canal Treatment
6. Periapical surgeries

The ultimate goal of conservative dentistry is to preserve natural dentition or to restore it to the best state of health, function and esthetics.

Restorative dentistry

Restorative dentistry is the study, diagnosis and integrated management of diseases of the teeth and their supporting structures and the rehabilitation of the dentition to functional and aesthetic requirements of the individual. Restorative dentistry encompasses the dental specialties of endodontics, periodontics and prosthodontics and its foundation is based upon how these interact in cases requiring multifaceted care. In the UK restorative dentistry is legally recognized as a specialty under EU directive, with voices from the British Society for Restorative Dentistry and the Association of Consultants & Specialists in Restorative Dentistry.

Dental public health

Dental public health is a non-clinical speciality of Dentistry.

Dental public health is involved in the assessment of dental health needs and improving the dental health of populations rather than individuals.

There are a few training opportunities to obtain an MSc in Dental public health.

One of the controversial subjects relating to dental public health is Fluoridation of drinking water. Another media blow-up has been associated with the commercial mouthwashes, of which an oral cancer is blamed for the fruit of the consumption.

Academic resources

• Journal of Public Health Dentistry

There seems to be a lot more that can be done to help individuals prevent tooth decay based on what is already known.

Even with fluoridation and oral hygiene, tooth decay is still the most common food related disease affecting all families, having the economic impact of heart disease, obesity and diabetes.

However decay is easy to prevent with a national project like Supertooth.org to reduce acid demineralisation from food left on teeth, neutralise acid and remineralise demineralised tooth after eating, or at least twice a day chewing a special form of toothpaste before or after brushing.

All cavities occur from acid demineralisation of teeth where chewing leaves food trapped on teeth. Though more than 95% of trapped food is left packed between teeth after every meal or snack, over 80% of cavities develop inside pits and fissures in grooves on chewing surfaces where the brush and fluoride toothpaste cannot reach.

Fissure sealants painted over chewing surfaces blocks food being trapped inside pits and fissures and changed to acid helping prevent acid demineralisation and tooth decay about as much as fluoridation where over 80% of cavities occur.

Chewing fibre like celery after eating helps force saliva inside pits and fissures and between teeth to dilute carbohydrate like sugar in trapped food, neutralise acid and remineralise tooth better than chewing gum that cannot absorb or expel saliva.

Chewing toothpaste before or after brushing would help fluoride remineralise susceptible tooth surfaces between teeth and inside pits and fissures where brushing cannot reach.

We already know how to prevent tooth decay but need to make it simple, convenient and easy.

Prosthodontics

Prosthodontics is one of nine dental specialties recognized by the American Dental Association, Royal College of Dentists of Canada, and Royal Australasian College of Dental Surgeons. Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes.

A prosthodontist is a dentist who specializes in prosthodontics, the specialty of implant, esthetic and reconstructive dentistry. Prosthodontists restore oral function through prostheses and restorations (i.e., complete dentures, crowns, implant retained/supported restorations). Cosmetic dentistry, implants and temporomandibular joint disorder all fall under the field of prosthodontics.

Training

The American College of Prosthodontists (ACP) ensures standards are maintained in the field. Becoming a prosthodontist requires an additional 3 years of postgraduate specialty training after obtaining a DDS (Doctor of Dental Surgery) or DMD (Doctor of Dental Medicine) degree. Training consists of rigorous preparation in the basic sciences, head and neck anatomy, esthetics, biomedical sciences, biomaterial sciences, function of occlusion (bite), TMD (Temporomandibular joint disorder), and full mouth treatment planning and reconstruction. Due to this extensive training, prosthodontists are frequently called upon to treat complex cosmetic cases, full mouth rehabilitation, TMJ related disorders, congenital disorders, and sleep apnea by planning and fabricating various prostheses. The ADA does not recognize any branch of dentistry called "cosmetic dentistry". Prosthodontics is the only dental speciality under which esthetic/cosmetic dentistry falls. Thus, prosthodontists are the only specialists who are trained as cosmetic dentists, as recognized by the ADA, and often encounter clinical challenges to fix failed treatments rendered by nonqualified "cosmetic dentists". Specifically, these treatment plans include failed full mouth reconstructions performed by general dentists who underwent a weekend or a week-long course prior to treating patients. It has also been argued that it is unethical for a general dentist to perform full mouth reconstruction type of treatment as they are not qualified specialists to perform these types of treatment.(Journal of Prosthodontics, Volume 18, Issue 4 (p 291-291)

Board Certification

Board certification is awarded through the American Board of Prosthodontics (ABP) and requires successful completion of the Part I written examination and Part 2, 3 and 4 oral examinations. This is a very rigorous process and so far there are no more than 800 diplomates, thus making diplomates exceptionally qualified . The written and one oral examination may be taken during the 3rd year of speciality training and the remaining two oral examinations taken following completion of speciality training. Board eligibility starts when an application is approved by the ABP and lasts for six years . Diplomates of the ABP are ethically required to have a practice limited to prosthodontics. Fellows of the American College of Prosthodontists (FACP) are required to have a dental degree, have completed three years of prosthodontic speciality training, and be board certified by the ABP.

Maxillofacial Prosthodontics

Maxillofacial prosthodontics is a subspecialty of prosthodontics. Maxillofacial prosthodontists treat patients who have acquired and congenital defects of the head and neck (maxillofacial) region due to surgery, trauma, and/or birth defects. Artificial eyes (see Ocularist, Ocular prosthetic), ears, and maxillary obturators are commonly planned and fabricated by maxillofacial prosthodontists. Other less commonly employed prostheses include mouth devices used by amputees to aid in daily activities, tracheostomy obturators, and craniofacial prosthesis.

Treatment is multidisciplinary involving oral and maxillofacial surgeons, plastic surgeons, ENT surgeons, oncologists, speech therapists, occupational therapists, physiotherapists, and other healthcare professionals.

To be qualified as a Maxillofacial Prosthodontist in the US, requires an additional year of training after completing a 3 year residency training in a Prosthodontics program. Due to their extensive training, breadth of knowledge and capabilities to handle any kind of a complex case, Maxillofacial Prosthodontists are often called as "Bullet-Proof" dentists.

Conditions and Treatment Modalities

• Akers' Clasp
• Amalgam (dentistry)
• Bisphosphonate-associated osteonecrosis of the jaws
• Bridge (dentistry)
• Bruxism
• Centric relation
• Commonly used terms of relationship and comparison in dentistry
• Crown (dentistry)
• Crown lengthening
• Crown-to-root ratio
• Curve of spee
• Dental implant
• Dental Phobia
• Dental Surgery
• Dentures
• Edentulism
• Fixed prosthodontics
• Head and neck anatomy
• Inlays and onlays
• Occlusal trauma
• Occlusion
• Temporomandibular joint disorder

Periodontics

Periodontology, or Periodontics, is the branch of dentistry which studies supporting structures of teeth, and diseases and conditions that affect them.

The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. The word comes from the Greek words peri meaning around and odons meaning tooth. Literally taken, it means study of that which is "around the tooth".

Periodontal disease

Periodontal diseases take on many different forms but are usually a result of a coalescence of bacterial plaque biofilm accumulation of the gingiva and teeth, combined with host immuno-inflammatory mechanisms and other risk factors which lead to destruction of the supporting bone around natural teeth. Untreated, these diseases lead to alveolar bone loss and tooth loss and, to date, continue to be the leading cause of tooth loss in adults.

Periodontists

A Periodontist is a dentist who specializes in the prevention, diagnosis, and treatment of periodontal diseases, and the surgical placement and long term maintenance of dental implants.

United States

Periodontology is one of the nine recognized dental specialties of the American Dental Association. The American Academy of Periodontology is the governing body for the specialty in the United States.

Periodontists (USA) must complete a 4 year undergraduate college degree, then graduate from an accredited dental school (DDS or DMD degree), and then complete an additional 3 to 7 years of formal training in an accredited periodontology residency program (obtaining a certificate and sometimes a Master of Science / Doctor of Science / Doctor of Medical Science / Doctor of Philosophy degrees in Periodontology). The focus of periodontal residency training is on learning skills for: the surgical and non-surgical management of periodontal diseases, the surgical treatment of correcting gingival abnormalities (gingival recession, gummy smiles, etc), all phases of dental implant treatment planning and surgery, and management of dental implant complications.

Periodontists may also earn Board Certification by the American Board of Periodontology after completion of an American Dental Association accredited residency training program in Periodontics and passing a comprehensive written and oral exam. Board Certified periodontists are awarded the title "Diplomate of the American Board of Periodontology".

Famous periodontists include Sigurd Ramfjord, Jorgen Slots, Jan Lindhe, Hessam Nowzari, Sture Nyman, Gerald Bowers, Edward A. Marcus, Harold Loe, Robert Schallhorn, Fermin Carranza, James Mellonig, Stuart Froum, Dennis Tarnow, Clifford Ochsenbein, and William V. Giannobile.

India

Periodontics is offered as a specialization field of dentistry in India. Periodontists attend a Master of Dental Surgery (M.D.S) program affiliated with dental schools in India. The minimum qualification required for the M.D.S degree is a Bachelor of Dental Surgery (B.D.S) degree.

United Kingdom

The British Society of Periodontology exists to promote the art and science of periodontology. Their membership includes specialist practitioners, periodontists, general dentists, consultants and trainees in restorative dentistry, clinical academics, dental hygienists and therapists, specialist trainees in periodontology, and many others.