Dental Health Care...

Temporomandibular joint disorder

2009-10-13T07:54:00.000-07:00


Temporomandibular joint

Temporomandibular joint disorder (TMJD 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.

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 dysfunction. 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:

Trauma
Repetitive unconscious jaw movements called bruxing.
Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
Jaw thrusting (causing unusual speech and chewing habits).
Excessive gum chewing or nail biting.
Size of foods eaten.
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
Myofascial pain dysfunction syndrome
Lack of Overbite

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.

Tooth impaction

2009-10-13T07:50:00.001-07:00

A digital X-ray film revealing an impacted permanent canine. The small tooth (bottom center) is the primary canine that has not fallen out because the permanent canine has become impacted in an abnormal direction.

Impacted and embedded teeth are the two main types of unerupted teeth found in the mouth, and can sometimes be confused with each other.

An orthopantomogram revealing four impacted Wisdom teeth.

In cases of both impacted and embedded teeth, the teeth remain below the surface of the gum and sometimes bone, rather than erupting into an exposed position within the mouth; however, the reason for the failure to erupt differs. Impacted teeth result from a situation in which an unerupted tooth is wedged against another tooth or teeth or otherwise directed so that it cannot erupt normally. In contrast, an embedded tooth is an unerupted tooth that is covered, usually completely, with bone. The former is "physically" blocked in its path of eruption, while the latter is compromised by its lack of eruptive force often without known etiology. Certain systemic and local pathologic conditions may be associated with both (i.e., cleidocranial dysostosis).

Impaction classifications

There are numerous classification systems used to identify the specific manner in which a tooth is impacted. One of the most simple distinctions made is whether a tooth is impacted completely within bone or whether it has broken through the bony cortex and is partially or completely covered in gingival tissue; the former would be termed bony impaction, while the latter would be termed soft-tissue impaction, and both classifications may present as partial or complete.^[1]

Mandibular third molars are the most commonly found unerupted teeth, while maxillary third molars are second most common.

Alveolar osteitis

2009-10-13T07:50:00.000-07:00

Labeled photograph of alveolar osteitis ("dry socket"), one week post-operative.

In dentistry, a dry socket is a layman's term for alveolar osteitis. The alveolus is the part of the jawbone that supports the teeth, and osteitis means simply “bone inflammation”. It is an irritation of the bone open to the oral cavity after the loss of or premature disintegration of the blood clot.

Alveolar osteitis is a painful phenomenon that most commonly occurs a few days following the removal of mandibular (lower) wisdom teeth. It occurs when the blood clot within the healing tooth extraction site is disrupted. In rare cases, the removal of the upper wisdom teeth can also result in alveolar osteitis.

Signs and symptoms

As with any extraction of a tooth, some pain is to be expected, as the gums surrounding the former location will be damaged to a certain degree. This is especially so in extractions of impacted wisdom teeth, which may not have properly erupted; in these cases, the gums are cut open to allow access to the tooth, then sutured shut.

However, a dry socket typically presents as a sharp and sudden increase in pain commencing 2–5 days following the extraction of a mandibular molar, most commonly the third molar. It can also be accompanied by a foul taste or smell.

The pain, which often radiates up and down the head and neck, can be extremely unpleasant for the patient. It will often cause pain in the ears as well. A dry socket is not an infection, and is not directly associated with swelling because it occurs entirely within bone — it is a phenomenon of inflammation within the bony lining of an empty tooth socket.

Prevention

True alveolar osteitis, as opposed to simple postoperative pain, occurs in only about 5–10% of extractions (primarily of the lower molar teeth). No one knows for certain how or why dry sockets develop following dental extraction but certain factors are associated with increased risk. One of these factors is the complexity of the extraction. Smoking, which can impede healing of wounds anywhere in the body, is another possible contributing factor, possibly due to the decreased amount of oxygen available in the healing tissues. It is advisable to avoid smoking for at least 48 hours following tooth extraction to reduce the risk of developing dry socket. Additional factors increasing risk of dry socket include the use of hormonal contraception by female patients, and the amount of surgically-induced trauma to the bone required at the time of the procedure (for this reason, operator experience plays a role). Women are generally at higher risk than men of developing dry socket, because estrogen slows down healing. Dentists recommend that their female patients have extractions performed during the last week of their cycle, when estrogen levels are lowest, to minimize chances of developing dry socket.

Patients are also advised to avoid drinking through a straw as the negative pressure created by drawing liquids through the straw can dislodge the clot. Additionally, patients may be told not to spit out saliva (or anything else for that matter) excessively due to the negative pressure created in the mouth immediately prior to spitting. Maintaining good oral hygiene during the healing period by brushing all non-tender areas regularly and rinsing with warm salt water is often advised, beginning 24 hours after the extraction.

Treatment

The pain from alveolar osteitis usually lasts for 24–72 hours. There is no real treatment for dry socket — it is a self-limiting condition that will improve and disappear with time — but certain interventions can significantly decrease pain during an episode of dry socket. These interventions usually consists of a gentle rinsing of the inflamed socket followed by the direct placement with in the socket of some type of sedative dressing, which soothes the inflamed bone for a period of time and promotes tissue growth. This is usually done without anesthesia. The active ingredients in these sedative dressings usually include natural substances like zinc oxide, eugenol, and oil of cloves. It is usually necessary to have this done for two or three consecutive days, although occasionally it can take longer. Because true dry socket pain is so intense, additional analgesics are sometimes prescribed.

Tooth Interior Fatigue Fracture

2009-10-13T07:46:00.001-07:00

Tooth Interior Fatigue Fracture (TIFF) on intermediate gear

The TIFF fracture surface has a distinct plateau in the central part along the tooth width and approximately mid-height of the tooth.

Tooth Interior Fatigue Fracture, (TIFF), is a type of gear failure. The failure is characterised by a fracture at approximately mid-height on the tooth of the gear. This distinguishes it from a tooth root fatigue failure. The crack for a TIFF is initiated in the interior of the tooth. This distinguishes TIFF from other fatigue failures of gears. TIFF has been observed in case-hardened idlers (i.e. gear wheels loaded on both flanks during each revolution).

The TIFF fracture surface has a distinct plateau in the central part along the tooth width and approximately mid-height of the tooth. In a close-up of the cross-section of the TIFF small wing cracks are observed. The presence of the wing crack indicates that the main crack has propagated from the centre of the tooth toward the tooth flank.

The crack-producing stresses of TIFF are twofold: i) constant residual tensile stresses in the interior of the tooth due to case hardening; and ii) alternating stresses due to the idler usage of the gear wheel.

Contact fatigue begins with surface distress, which can grow to spalling. In severe cases a secondary crack can grow from a spalling crater through the tooth thickness and a part of the tooth can fall off. In contrast to the fracture of severe contact fatigue, spalling craters are not necessary at the flank surface for a TIFF.

Tooth loss

2009-10-13T07:43:00.000-07:00

A young boy after losing two baby teeth, exfoliated in response to the permanent teeth beneath, which will erupt through the gums to take their place.

Tooth loss is when one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth (baby teeth), when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as mouth trauma, tooth injury, tooth decay, and gum disease. The condition of being toothless or missing one or more teeth, is called edentulism.

Prevention of tooth loss

Tooth loss due to tooth decay and gum disease may be prevented by practicing good oral hygiene, and regular check-ups (twice per year) at the dentist's office.

In contact sports, risk of mouth trauma and tooth injury is reduced by wearing mouthguards and helmets with a facemask (e.g., football helmet, and goalie mask).

Missing tooth replacement

There are three basic ways to replace a missing tooth or teeth, including a fixed dental bridge, dentures, and dental implants.

Research in tooth regeneration

Researchers in Japan have successfully regrown fully functional teeth in mice. Epithelial and mesenchymal cells were extracted from the mice, cultured to produce a tooth "germ," and the germ was then implanted into the bone at the space of a missing tooth. A tooth of the correct external and internal structure, hardness, strength and sensitivity later erupted in the space, eventually meeting the opposing tooth in a manner similar to an original natural tooth. This technique may be a possible future treatment for replacement of missing teeth.

Tooth abscess

2009-10-13T07:31:00.000-07:00

A tooth abscess or root abscess is pus enclosed in the tissues of the jaw bone at the tip of an infected tooth. Usually the abscess originates from a bacterial infection that has accumulated in the soft pulp of the tooth.

Abscesses typically originate from dead pulp tissue, usually caused by untreated tooth decay, cracked teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

There are three types of dental abscess. A gingival abscess that involves only the gum tissue, without affecting either the tooth or the periodontal ligament. A periapical abscess starts in the dental pulp. A periodontal abscess begins in the supporting bone and tissue structures of the teeth.

Presentation and symptoms

"The main symptom is a severe toothache. The pain is continuous and may be described as gnawing, sharp, shooting, or throbbing." Putting pressure or warmth on the tooth may induce extreme pain. There may be a swelling present at either the base of the tooth, the gum, and/or the cheek.

A chronic abscess may be painless but still have a swelling present on the gum. It is important to get anything that presents like this checked by a dental professional as it may become acute later.

In some cases, a tooth abscess may perforate bone and start draining into the surrounding tissues creating local facial swelling. In some cases, the lymph glands in the neck will become swollen and tender in response to the infection. It may even feel like a migraine as the pain can transfer from the infected area. The pain does not normally transfer across the face, only upwards or downwards as the nerves that serve each side of the face are separate.

Treatment

In the short term, the topical application of oil of cloves, which contains Eugenol, to the infected area is well-documented as an effective remedy.

Successful treatment of a dental abscess centers on the reduction and elimination of the offending organisms. If the tooth can be restored, root canal therapy can be performed. Nonrestorable teeth must be extracted, followed by curettage of all apical soft tissue.

Unless they are symptomatic, teeth treated with root canal therapy should be evaluated at 1- and 2-years intervals to rule out possible lesional enlargement and to ensure appropriate healing.

Abscesses may fail to heal for several reasons:

Cyst formation
Inadequate root canal therapy
Vertical root fractures
Foreign material in the lesion
Associated periodontal disease
Penetration of the maxillary sinus

Following conventional, adequate root canal therapy, abscesses that do not heal or enlarge are often treated with surgery and filling the root tips; and will require a biopsy to evaluate the diagnosis.

Untreated consequences

If left untreated, a severe tooth abscess may become large enough to perforate bone and extend into the soft tissue eventually becoming osteomyelitis and cellulitis respectively. From there it follows the path of least resistance and may spread either internally or externally. The path of the infection is influenced by such things as the location of the infected tooth and the thickness of the bone, muscle and fascia attachments.

External drainage may begin as a boil which bursts allowing pus drainage from the abscess, intraorally (usually through the gum) or extra orally. Chronic drainage will allow an epithelial lining to form in this communication to form a pus draining canal (fistula). Sometimes this type of drainage will immediately relieve some of the painful symptoms associated with the pressure.

Internal drainage is of more concern as growing infection makes space within the tissues surrounding the infection. Severe complications requiring immediate hospitalisation include Ludwig's angina, which is a combination of growing infection and cellulitis which closes the airway space causing suffocation in extreme cases. Also infection can spread down the tissue spaces to the mediastinum which has significant consequences on the vital organs such as the heart. Another complication, usually from upper teeth, is a risk of septicaemia (infection of the blood), from connecting into blood vessels, brain abscess, (extremely rare) or meningitis, (also rare).

Depending on the severity of the infection, the sufferer may feel only mildly ill, or may in extreme cases require hospital care.

Bruxism

2009-10-13T07:21:00.000-07:00


A profile of a smile, exhibiting significant wear, especially on the maxillary incisors. Even though the teeth are in an edge-to-edge position, the teeth are in maximum intercuspation; this patient possesses a Class III occlusion.

Bruxism (from the Greek βρυγμός (brugmós), "gnashing of teeth") is characterized by the grinding of the teeth and is typically accompanied by the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem. While bruxism may be a diurnal or nocturnal activity, it is bruxism during sleep that causes the majority of health issues and can even occur during short naps. Bruxism is one of the most common sleep disorders.

Etiology

Numerous articles have incorrectly cited bruxism as being a reflex chewing activity, but bruxism is more accurately classified as a habit. Reflex activities happen reliably in response to a stimulus, without involvement of subconscious brain activity, and bruxism does not. All habitual activities are triggered by one kind of stimulus or another, and that does not make the habit a reflex. Chewing is a complex neuromuscular activity that is controlled by subconscious processes, with higher control by the brain. During sleep, the subconscious processes become active, while the higher control is inactive, resulting in bruxism. Some bruxism activity is rhythmic (like chewing), and some is sustained (clenching). Researchers classify bruxism as "a habitual behavior, and a sleep disorder."

The etiology of problematic bruxism is unknown, though several conditions are known to be linked to bruxism. It is theorized that certain medical conditions can trigger bruxism, including digestive ailments and anxiety.

Signs

The effects of bruxism on an anterior tooth, revealing the dentin and pulp which are normally hidden by enamel

Most bruxers are not aware of their bruxism, and only 5% go on to develop symptoms, such as jaw pain and headaches, which will require treatment. In many cases, a sleeping partner or parent will notice the bruxism before the person experiencing the problem becomes aware of it.

Bruxism can result in abnormal wear patterns of the occlusal surface, abfractions and fractures in the teeth. This type of damage is categorised as a sign of occlusal trauma.

Over time, dental damage will usually occur. Bruxism is the leading cause of occlusal trauma and a significant cause of tooth loss and gum recession.

In a typical case, the canines and incisors of the opposing arches are moved against each other laterally, i.e., with a side-to-side action, by the medial pterygoid muscles that lie medial to the temporomandibular joints bilaterally. This movement abrades tooth structure and can lead to the wearing down of the incisal edges of the teeth. People with bruxism may also grind their posterior teeth, which will wear down the cusps of the occlusal surface. Bruxism can be loud enough to wake a sleeping partner. Some individuals will clench the jaw without significant lateral movements. Teeth hollowed by previous decay (caries), or dental drilling, may collapse, as the cyclic pressure exerted by bruxism is extremely taxing on the tooth structure.

Symptoms

Patients may present with a variety of symptoms, including:

Morning migraines
Morning headaches
Jaw pain
TMJ pain
Facial muscle and nerve pain
Earache
Sinus pain
Tinnitus (ringing in the ear)
Vertigo
Neck pain
Shoulder pain
Back pain
Poor sleep
Waking exhausted
Stress or tension
Depression
Eating disorders
Insomnia
Daytime sleepiness
Eye irritation
Head tingling

Sequelae

Eventually, bruxism shortens and blunts the teeth being ground and may lead to myofacial muscle pain, temporomandibular joint dysfunction and headaches. In severe, chronic cases, it can lead to arthritis of the temporomandibular joints. The jaw clenching that often accompanies bruxism can be an unconscious neuromuscular daytime activity, which should be treated as well, usually through physical therapy (recognition and stress response reduction).

Diagnoses

Bruxism can sometimes be difficult to diagnose by visual evidence alone, as it is not the only cause of tooth wear. Over-vigorous brushing, abrasives in toothpaste, acidic soft drinks and abrasive foods can also be contributing factors, although each causes characteristic wear patterns that a trained professional can identify. Additionally, the presenting symptoms may be difficult for a physician to attribute to bruxism.

The effects of bruxism may be quite advanced before sufferers are aware they brux. Abraded teeth are usually brought to the patient's attention during a routine dental examination. If enough enamel has been abraded, the softer dentin will be exposed, and abrasion will accelerate. This opens the possibility of dental decay and tooth fracture, and in some people, gum recession. Early intervention by a dentist is advisable.

The most reliable way to diagnose bruxism is through EMG (electromyographic) measurements. These measurements pick up electrical signals from the chewing muscles (masseter and temporalis). This is the method used in sleep labs. There are three forms of EMG measurement available to consumers for use outside sleep labs. The first is bedside EMG units similar to those used by sleep labs. These units can be purchased for about $2000 and pick up their signals from facial muscles through wires connecting the bedside unit to electrodes that are adhesively attached to the user's face. TENS electrodes or ECG electrodes may be used.

The second type of EMG measurement available to consumers is a self-contained EMG measurement headband sold under the trade name SleepGuard, available on loan from some dentists or at a rental rate of $50 per month from the manufacturer. The EMG measurement headband does not require adhesive electrodes or wires attached to the face. While it does not record the exact time, duration, and strength of each clenching incident as the most expensive bedside EMG monitors do, it does record the total number of clenching incidents and the total clenching time each night. These two numbers easily distinguish clenching from rhythmic grinding and allow dentists to quantify severity levels accurately.

Bedside EMG units and the self-contained EMG measurement headband can both be used either in silent mode as a diagnosis measurement or in biofeedback mode as a treatment.

A third method of diagnosis using EMG is available in disposable form under the trade name BiteStrip. The BiteStrip is a self-contained EMG module that adhesively mounts to the side of the face over the masseter muscle. The BiteStrip can only do one night of measurement and does not display the clench count or total clenching time, but rather provides a single-digit display related to bruxism severity. The BiteStrip provides significantly less information than an EMG bedside unit or EMG headband and costs about $60 per day to use.

Associated factors

The following factors are associated with bruxism.

Disturbed sleep patterns and other sleep disorders (obstructive sleep apnea, hypopnea, snoring, moderate daytime sleepiness)
Malocclusion, in which the upper and lower teeth occlude in a disharmonic way, e.g., through premature contact of back teeth^{[citation needed]}
Relatively high levels of consumption of caffeinated drinks and foods, such as coffee, colas, and chocolate
High levels of blood alcohol
Smoking
High levels of anxiety, stress, work-related stress, irregular work shifts, stressful profession and ineffective coping strategies
Drug use, such as SSRIs and stimulants, including methylenedioxymethamphetamine (ecstasy), methylenedioxyamphetamine (MDA), methylphenidate and other amphetamines, including those taken for medical reasons
Hypersensitivity of the dopamine receptors in the brain
GHB and similar GABA-inducing analogues such as Phenibut, when taken with high frequency
Disorders such as Huntington's and Parkinson's diseases
Obsessive Compulsive Disorder
Chemical drugs

Treatment

There is no single accepted cure for bruxism. However, treatments are available.

Bruxism may be reduced or even eliminated when the associated factors, e.g., sleep disorders, are treated successfully.

Mouthguards and splints

Ongoing management of bruxism is based on minimizing the abrasion of tooth surfaces by the wearing of an acrylic dental guard, or splint, designed to the shape of an individual's upper or lower teeth from a bite mould. Mouthguards are obtained through visits to a dentist for measuring, fitting, and ongoing supervision. There are four possible goals of this treatment: constraint of the bruxing pattern such that serious damage to the temporomandibular joints is prevented, stabilization of the occlusion by minimizing the gradual changes to the positions of the teeth that typically occur with bruxism, prevention of tooth damage, and the enabling of a bruxism practitioner to judge—in broad terms—the extent and patterns of bruxism through examination of the physical indentations on the surface of the splint. A dental guard is typically worn on a long-term basis during every night's sleep. Although mouthguards are a first response to bruxism, they do not in fact help cure it. An otc soft mouthguard is not considered effective by most. These mouthguards can cost anywhere from $200 to $400.

Professional treatment is medically recommended to ensure proper fit, make ongoing adjustments as needed, and check that the occlusion (bite) has remained stable. Monitoring of the mouthguard is suggested at each dental visit.

Another type of device sometimes given to a bruxer is a repositioning splint. A repositioning splint may look similar to a traditional night guard, but is designed to change the occlusion, or bite, of the patient. Randomly controlled trials with these type devices generally show no benefit over more conservative therapies, and they should be avoided under most, if not all, circumstances.

The NTI-tss device is another option that can be considered. The NTI covers only the front teeth and prevents the rear molars from coming into contact, thus limiting the contraction of the temporalis muscle. The NTI must be fitted by one's dentist.

The efficacy of such devices is debated. Some writers propose that irreversible complications can result from the long-term use of mouthguards and repositioning splints.

Biofeedback

Various biofeedback devices are currently available, and effectiveness varies significantly depending on whether the biofeedback is used only during waking hours, or during sleep as well. Many authorities remain unconvinced of the efficacy of daytime-only biofeedback. The efficacy of biofeedback delivered during sleep can depend strongly on daytime training, which is used to establish a Pavlovian response to the biofeedback signal that persists during sleep.

The first wearable nighttime bruxism biofeedback device (a biofeedback headband introduced in 2001) was originally sold under the trademark GrindAlert by BruxCare and is now sold under the GrindAlert and SleepGuard trademarks by Holistic Technologies, which holds an exclusive worldwide license to the technology. The biofeedback headband is a battery-powered device that sounds a tone against the forehead when it senses EMG (electromyographic) muscle activity in the temporalis muscles. This device records and displays nightly data on the number of bruxism events that last for at least two seconds and the total accumulated duration of those events. The volume of the alarm and the bite force required to trigger the device are adjustable. After proper Pavlovian training during waking hours, more than 25% of users achieve significantly reduced bruxism. The biofeedback sound on the headband is designed to come on slowly, allowing users to subconsciously respond in their sleep without waking up. The manufacturer offers a free three-week trial so that only people who find the device works well for them have to pay for it and claims that less than 15% of trial units are returned.

A mild electric shock bio-feedback device for treating Bruxism, GrindCare, has been approved by the European regulatory authorities and was introduced to the market in 2008. The GrindCare device infringes the US patents on the SleepGuard/GrindAlert device, so the GrindCare device is not legal to import into the United States without a license from Holistic Technologies. The device works by using simple electrodes mounted on the skin close to the cheek bones prior to sleeping; it detects the initial muscular contractions and immediately provides insignificant pulses to the facial muscles, whereby the contractions are stopped. The device is worn on the head and reportedly reduces grinding without interfering with the sleep of the patient as described by Jadidi, Castrillon & Svensson. Thereby, facial tension, joint defects and teeth disruption are reportedly reduced.

A taste-based biofeedback method was developed by Moti Nissani, Ph.D. and is called "The Taste-Based Approach to the Prevention of Teeth Clenching and Grinding". The therapy involves suspending sealed packets containing a bad-tasting substance (e.g. hot sauce, vinegar, denatonium benzoate, etc.) between the rear molars using an orthodontic-style appliance. Any attempt to bring the teeth together will rupture the packets and alert the user to the habit. This approach finds favor with some people who prefer to relate to biofeedback as "aversive therapy". The Taste-Based Approach claims to suffer less from desensitization over time than sound-based biofeedback approaches may have, but may interrupt sleep more. (There is effectively no limit to the aversive taste of certain substances. We can therefore be sure that some harmless substance exists that will alert anyone to the habit.)

One bruxism biofeedback device which was briefly on the market but is no longer available was sold under the trademark Oralsensor. This device consisted of a pneumatic pouch embedded in a soft polymer plate that fits over upper or lower teeth. When the teeth came together with a force that exceeded a set threshold, an alarm is sounded in an earpiece worn by the user; the device is no longer sold.

In 2005, a new type of occlusive device was patented that produces a movement incompatible with teeth clenching. When nighttime bruxism occurs, people breathe through the nose. The device forces people to breathe through the mouth; by forcing the opening of the mouth, the device is claimed to stop clenching. The occlusive device has an electromyogram system that monitors the electric activity of the jaw muscle via wireless electrodes. These electrodes transfer jaw-muscle activity by radio frequency to an external monitoring system. Once the signal has been interpreted by the monitoring system, if a person clenches, the monitoring unit sends a radio frequency signal to a transceiver integrated in a mechanical actuator. The mechanical actuator has two occlusive flaps that block the nostrils, forcing breathing to occur through the mouth. Once the patient stops clenching, the flaps open, allowing breathing through the nose again. The occlusive device does not wake up people since it blocks nostrils slowly, and it never closes them completely to avoid sleep disruption.

Botox

Botulinum toxin (Botox) can be successful in lessening effects of bruxism, though serious side-effects are possible. Less than one microgram ingested or inhaled is sufficient to kill an adult human. In extremely dilute form (Botox), this toxin is used as an injectable medication that weakens (partially paralyzes) muscles and has been used extensively in cosmetic procedures to relax the muscles of the face and decrease the appearance of wrinkles. In April, 2008, a study was published in the Journal of Neuroscience that showed that facially injected Botox can and does propagate into the brains of some test animals, and the U.S. Food and Drug Administration (FDA) announced that it was beginning a safety review of Botox and other similar drugs.

Botox was not originally developed for cosmetic use. It was, and continues to be, used to treat diseases of muscle spasticity such as blepharospasm (eyelid spasm), strabismus (crossed eyes) and torticollis (wry neck). Bruxism can also be regarded as a disorder of repetitive, unconscious contraction of the masseter muscle (the large muscle that moves the jaw). In the treatment of bruxism, Botox works to weaken the muscle enough to reduce the effects of grinding and clenching, but not so much as to prevent proper use of the muscle. The strength of Botox is that the medication goes into the muscle and is not supposed to get absorbed into the body (though the new research shows it does). The procedure involves about five or six simple, relatively painless injections into the masseter muscle. It takes a few minutes per side, and the patient starts feeling the effects the next day. Occasionally, some bruising can occur, but this is quite rare. Injections must be repeated more than once per year, and the risk factor of spread of the botulinum toxin is compounded by this repetition.

The symptoms that can be helped by this procedure include:

Grinding and clenching
Morning jaw soreness
TMJ pain
Muscle tension throughout the day
Migraines triggered by clenching
Neck pain and stiffness triggered by clenching

The optimal dose of Botox must be determined for each person as some people have stronger muscles that need more Botox. This is done over a few touch-up visits with the physician injector. This treatment is expensive, but sometimes Botox treatment of bruxism can be billed to medical insurance. The effects last for about three months. The muscles do atrophy, however, so after a few rounds of treatment, it is usually possible either to decrease the dose or increase the interval between treatments.

Other authorities caution that Botox should only be used for temporary relief for severe cases and should be followed by diagnosis and treatment to prevent future bruxism or jaw clenching, suggesting that prolonged use of Botox can lead to permanent damage to the jaw muscle.

Dietary supplements

There is anecdotal evidence that suggests taking certain combinations of dietary supplements may alleviate bruxism; pantothenic acid, magnesium, and calcium are mentioned on dietary supplement websites. Calcium is known to be a treatment for gastric problems, and gastric problems such as acid reflux are known to increase bruxism.

Repairing damage

Damaged teeth can be repaired by replacing the worn natural crown of the tooth with prosthetic crowns. Materials used to make crowns vary; some are less prone to breaking than others and can last longer. Porcelain fused to metal crowns may be used in the anterior (front) of the mouth; in the posterior, full gold crowns are preferred. All-porcelain crowns are now becoming more and more common and work well for both anterior and posterior restorations. To protect the new crowns and dental implants, an occlusal guard should be fabricated to wear during sleep.

Third molar

2009-10-13T07:17:00.000-07:00

Third molar teeth (commonly referred to as wisdom teeth) consist of the mandibular and maxillary third molars; they usually appear between the ages of 17 and 25. They are called wisdom teeth because usually they come in when a person is between age 17 and 25 or older—old enough to have supposedly gained some wisdom. Most adults have four wisdom teeth, but it is possible to have more or fewer. Absence of one or more wisdom teeth is an example of hypodontia. Any extra teeth are referred to as supernumerary teeth. Wisdom teeth commonly affect other teeth as they develop - becoming impacted or "coming in sideways." They are often extracted when this occurs.

Etymology of "wisdom teeth"

They are generally thought to be called wisdom teeth because they appear so late—much later than the other teeth, at an age where people are presumably wiser than as a child, when the other teeth erupt. The English wisdom tooth is derived from Latin dens sapientiae. The same root is shared by numerous other languages. There exists a Dutch folk etymology which states that the Dutch word for wisdom tooth verstandskies is derived from "far-standing" (ver-staand) molar, and that mistranslations of the Dutch word (in which verstand translates to wisdom) are the root for corresponding words in other European languages.

Impaction

The upper left (picture right) and upper right (picture left) wisdom tooth are distoangularly impacted. The lower left wisdom tooth is horizontally impacted. The lower right wisdom tooth is vertically impacted (unidentifiable in orthopantomogram).

Impacted wisdom teeth fall into one of several categories. Mesioangular impaction is the most common form (44%), and means the tooth is angled forward, towards the front of the mouth. Vertical impaction (38%) occurs when the formed tooth does not erupt fully through the gum line. Distoangular impaction (6%) means the tooth is angled backward, towards the rear of the mouth. And finally, Horizontal impaction (3%) is the least common form, which occurs when the tooth is angled fully ninety degrees forward, growing into the roots of the second molar.

Typically distoangular impactions are the easiest to extract in the maxilla and most difficult to extract in the mandible, while mesioangular impactions are the most difficult to extract in the maxilla and easiest to extract in the mandible. Frequently, a fully erupted upper wisdom tooth requires bone removal if the tooth does not yield easily to forceps or elevators. Failure to remove distal or buccal bone while removing one of these teeth can cause the entire maxillary tuberosity to be fractured off and thereby the tearing out the floor of the maxillary sinus.

Impacted wisdom teeth may also be categorized on whether they are still completely encased in the jawbone. If it is completely encased in the jawbone, it is a bony impaction. If the wisdom tooth has erupted out of the jawbone but not through the gumline, it is called a soft tissue impaction. Sometimes the wisdom tooth fails to erupt completely through the gum bed and the gum at the back of the wisdom tooth extends over the biting surface, forming a soft tissue flap or lid around the tooth called an operculum. Teeth covered by an operculum can be difficult to clean with a toothbrush. Additional cleaning techniques can include using a needle-less plastic syringe to vigorously wash the tooth with moderately pressured water or to softly wash it with hydrogen peroxide.

However, debris and bacteria can easily accumulate under an operculum, which may cause pericoronitis, a common infection problem in young adults with partial impactions that is often exacerbated by occlusion with opposing 3rd or 2nd molars. Common symptoms include a swelling and redness of the gum around the eruption site, difficulty in opening the mouth, a bad odor or taste in the mouth, and pain in the general area which may also run down the entire lower jaw or possibly the neck. Untreated pericoronitis can progress to a much more severe infection.

If the operculum does not disappear, recommended treatment is extraction of the wisdom tooth. An alternative treatment involving removal of the operculum, called operculectomy, has been advocated. There is a high risk of permanent or temporary numbness of the tongue due to damage of the nerve with this treatment and it is no longer recommended as a standard treatment in oral surgery.

The oldest known impacted wisdom tooth belonged to a European woman of the Magdalenian period (18,000 - 10,000 BP)

Extraction

A wisdom tooth protrudes outwards from the gumline at the back of the lower teeth.

A dental officer and his assistant remove the mandibular third molar of a patient.

An extracted mandibular third molar that was horizontally impacted.

An upper and lower right wisdom tooth extracted during the same session

under local anaesthetics.

Wisdom teeth are extracted for two general reasons: either the wisdom teeth have already become impacted, or the wisdom teeth could potentially become problematic if not extracted. Potential problems caused by the presence of properly grown-in wisdom teeth include infections caused by food particles easily trapped in the jaw area behind the wisdom teeth where regular brushing and flossing is difficult and ineffective. Such infections may be frequent, and cause considerable pain and medical danger. Other reasons wisdom teeth are removed include misalignment which rubs up against the tongue or cheek causing pain, potential crowding or malocclusion of the remaining teeth (a result of there being not enough room on the jaw/ in the mouth),as well as orthodontics.

A panoramic x-ray (aka "panorex") is the best x-ray to view wisdom teeth and diagnose problems.

Post-extraction problems

There are several problems that might occur after the extraction(s) have been completed. Some of these problems are unavoidable and natural, while others are under the control of the patient. The suggestions contained in the sections below are general guidelines that a patient will be expected to abide by, but the patient should follow all directions that are given by the surgeon in addition to the following guidelines. Above all, the patient must not disregard the given instructions; doing so is extremely dangerous and could result in any number of problems ranging in severity from being merely inconvenient (dry socket) to potentially life-threatening (serious infection of the extraction sites).

Cyst around right lower wisdom tooth.

Bleeding and oozing

Bleeding and oozing is inevitable and should be expected to last up to three days (although by day three it should be less noticeable). Rinsing the mouth during this period is counter-productive, as the bleeding stops when the blood forms clots at the extraction sites, and rinsing out the mouth will most likely dislodge the clots. The end result will be a delay in healing time and a prolonged period of bleeding. However, after about 24 hours post-surgery, it is best to rinse with lukewarm saltwater to promote healing. This should be done twice a day until the swelling goes down and every 4–6 hours after that for at least a week. Gauze pads should be placed at the extraction sites, and then should be bitten down on with firm and even pressure. This will help to stop the bleeding, but should not be overdone as it is possible to irritate the extraction sites and prolong the bleeding or remove the clot. The bleeding should decrease gradually and noticeably upon changing the gauze. If the bleeding lasts for more than a day without decreasing despite having followed the surgeon's directions, the surgeon should be contacted as soon as possible. This is not supposed to happen under normal circumstances and signals that a serious problem is present. A wet tea bag can replace the gauze pads.Tannic acid contained in tea can help reduce the bleeding.

Due to the blood clots that form in the exposed sockets as well as the abundant bacterial flora in the mouth, an offensive smell may be noticeable a short time after surgery. The persistent odor often is accompanied by an equally rancid-tasting fluid seeping from the wounds. These symptoms will diminish over an indefinite amount of time, although one to two weeks is normal. While not a cause for great concern, a post-operative appointment with one's surgeon seven to ten days after surgery is highly recommended to make sure that the healing process has no complications and that the wounds are relatively clean. If infection does enter the socket, a qualified dental professional can gently plunge a plastic syringe (without the hypodermic needle) full of a mixture of equal parts hydrogen peroxide and water or chlorohexidine gluconate which also comes in the form of a mouth wash into the sockets to remove any food or bacteria that may collect in the back of the mouth. This is less likely if the person has his/her wisdom teeth removed at an early age.

Dry socket

A dry socket is not an infection; it is the event where the blood clots at an extraction site are dislodged, fall out prematurely, or fail to form. It is still not known how they form or why they form. In some cases, this is beyond the control of the patient. However, in other cases this happens because the patient has disregarded the instructions given by the surgeon. Smoking, blowing one's nose, spitting, or drinking with a straw in disregard to the surgeon's instructions can cause this, along with other activities that change the pressure inside of the mouth, such as sneezing or playing a musical instrument. The risk of developing a dry socket is greater in smokers, if the patient has had a previous dry socket, in the lower jaw, and following complicated extractions. The extraction site will become irritated and painful, due to inflammation of the bone lining the tooth socket (osteitis). The symptoms are made worse when food debris is trapped in the tooth socket. The patient should contact their surgeon if they suspect that they have a case of dry socket. The surgeon may elect to clean the socket under local anesthetic to cause another blood clot to form or prescribe medication in topical form (e.g. Alvogel) to apply to the affected site. A non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be prescribed by the surgeon for pain relief. Generally dry sockets are self limiting and heal in a couple of weeks without treatment.

Swelling

Swelling should not be confused with dry socket, although painful swelling should be expected and is a sign that the healing process is progressing normally. There is no general duration for this problem; the severity and duration of the swelling vary from case to case. The instructions the surgeon will tell the patient for how long they should expect swelling to last, including when to expect the swelling to peak and when the swelling will start to subside. If the swelling does not begin to subside when it is supposed to, the patient should contact his or her surgeon immediately. While the swelling will generally not disappear completely for several days after it peaks, swelling that does not begin to subside or gets worse may be an indication of infection. Swelling that re-appears after a few weeks is an indication of infection caused by a bone or tooth fragment still in the wound and should be treated immediately.

Nerve injury

Mandibular division of trigeminal nerve, seen from the middle line.

This is primarily an issue with extraction of third molars, but can occur with the extraction of any tooth should the nerve be in close proximity to the surgical site. Two nerves are typically of concern and are found in duplicate (on the left and right side):

The inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip.
The lingual nerve, which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch).

Such injuries can occur while lifting teeth (typically the inferior alveolar) but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary. Depending on the type of injury (i.e. Seddon classification: neuropraxia, axonotmesis, and neurotmesis) they can be prolonged or permanent.

Treatment controversy

Preventive removal of the third molars is a common practice in developed countries despite the lack of scientific data to support this practice. In 2006, the Cochrane Collaboration published a systematic review of randomized controlled trials in order to evaluate the effect of preventive removal of asymptomatic wisdom teeth. The authors found no evidence to either support or refute this practice. There was reliable evidence showing that preventative removal did not reduce or prevent late incisor crowding. The authors of the review suggested that the number of surgical procedures could be reduced by 60% or more. This study, however, was published in the Journal of Phytology and is not accredited by many peer review organizations.

Likewise, ClinicalEvidence published a summary, largely based on the Cochrane review, that concluded prophylactic extraction is "likely to be ineffective or harmful." The website offered the following details:

While it is clear that symptomatic impacted wisdom teeth should be surgically removed, it appears that extracting asymptomatic, disease-free wisdom teeth is not advisable due to the risk of damage to the inferior alveolar nerve.

Some non-RCT evidence suggests that the extraction of the asymptomatic tooth may be beneficial if caries are present in the adjacent second molar, or if periodontal pockets are present distal to the second molar.

Studies showed that dentists graduated from different countries or even from different dental schools in one country, may have different clinical decisions regarding third molar removal for the same clinical condition. For example, dentists graduated from Israeli dental schools may recommend more often for the removal of asymptomatic impacted third molar than dentists graduated from Latin-American or Eastern European dental schools.

In the U.K., the National Institute for Health and Clinical Excellence (an authority which appraises the cost-effectiveness of treatments for the National Health Service) has recommended that impacted wisdom teeth that are free from disease should not be operated on. Conversely, in the U.S., the American Association of Oral and Maxillofacial Surgeons (the professional organization representing oral and maxillofacial surgeons in the United States) recommends that all wisdom teeth should be removed at an early age as a prophylactic measure. This would suggest that recommendations regarding the removal of third molars vary widely from country to country, depending on the stakeholders involved.

Vestigiality and variation

Wisdom teeth are vestigial third molars that human ancestors used to help in grinding down plant tissue. The common postulation is that the skulls of human ancestors had larger jaws with more teeth, which were possibly used to help chew down foliage to compensate for a lack of ability to efficiently digest the cellulose that makes up a plant cell wall. As human diets changed, smaller jaws gradually evolved, yet the third molars, or "wisdom teeth", still commonly develop in human mouths.

Other findings suggest that a given culture's diet is a larger factor than genetics in the development of jaw size during human development (and, consequently, the space available for wisdom teeth).

Different human populations differ greatly in the percentage of the population which form wisdom teeth. Agenesis of wisdom teeth ranges from 0.2% in Bantu speakers to nearly 100% in indigenous Mexicans. The difference is related to the PAX9 gene (and perhaps other genes).

Potential uses for extracted teeth

In August 2008, it was revealed that scientists in Japan were able to successfully harvest stem cells from wisdom teeth. This discovery is of great clinical importance, as wisdom tooth extractions are a relatively common type of oral surgery. Patients who have their wisdom teeth removed are currently able to opt to have stem cells from those teeth isolated and saved, in case they should ever need the cells.

Nail biting

2009-10-13T00:55:00.000-07:00

Fingers of an extreme nail-biter.

Onychophagia or nail biting is a common oral compulsive habit in children and adults, affecting around 30% of children between 7 to 10 years and 45% of teenagers.

Negative effects

Bitten fingertips can become very sensitive to pain, usually at the place the skin meets the edge of the nail. Hangnails are broken skin on the cuticle. When they are improperly removed, they are susceptible to microbial and viral infections producing whitlows. Saliva may then redden and infect the skin. Finally it may also result in the transportation of bacteria that are buried under the surface of the nail, or pinworms from anus region to mouth. Nail biting is also related to dental problems, such as gingival injury.

Regarding social effects the aesthetic aspect of the nail may affect employability, self-esteem, and interaction with other people.

Treatment

Behavioral treatments are based in discouraging the habit and replace it with a more constructive habit. The most common treatment, as it is cheap and widely available, is a special clear nail polish that has to be applied to the nails. It releases a bitter flavor on contact with the mouth which discourages the habit and has demonstrated its effectiveness. There are also mouthpieces that prevent biting.

Behavioral therapy is beneficial when simpler measures are not effective. Habit Reversal Training (HRT), seeks to "unlearn" the habit of nail biting and possibly replace it with a more constructive habit and has shown its effectiveness versus placebo both in children and adults. In addition to HRT, stimulus control therapy is used to both identify and then eliminate the stimulus that frequently triggers biting urges.

Finally nail cosmetics can help to ameliorate nail biting social effects.

Related disorders

Some related body-focused repetitive behaviors are dermatillomania (skin picking), dermatophagia (skin biting) or trichotillomania (urge to pull out hair).

Toothache

2009-09-01T06:24:00.000-07:00

A toothache, also known as odontalgia or, less frequently, as odontalgy, is an aching pain in or around a tooth. In most cases toothaches are caused by problems in the tooth or jaw, such as cavities, gum disease, the emergence of wisdom teeth, a cracked tooth, infected dental pulp (necessitating root canal treatment or extraction of the tooth), jaw disease, or exposed tooth root. Causes of a toothache may also be a symptom of diseases of the heart, such as angina or a myocardial infarction, due to referred pain. After having one or more teeth extracted a condition known as dry socket can develop, leading to extreme pain. The severity of a toothache can range from a mild discomfort to excruciating pain, which can be experienced either chronically or sporadically. This pain can often be aggravated somewhat by chewing or by hot or cold temperature. An oral examination complete with X-rays can help discover the cause. Severe pain may be considered a dental emergency. A special condition is barodontalgia, a dental pain evoked upon changes in barometric pressure, in otherwise asymptomatic but diseased teeth. Atypical odontalgia is a form of toothache present in apparently normal teeth. The pain, generally dull, often moves from one tooth to another for a period of 4 months to several years. This is most commonly reported by middle-aged women. The cause of atypical odontalgia is not yet clear.

Toothaches are sometimes caused by an irritation of the pulp, known as pulpitis. This can be either reversible or irreversible. Irreversible pulpitis can be identified by sensitivity and pain lasting longer than fifteen seconds, although an exception to this may exist if the tooth has been recently operated on. Teeth affected by irreversible pulpitis will need either a root canal or an extraction.

Dental caries

2009-09-01T05:59:00.002-07:00


Destruction of a tooth by cervical decay from dental caries. This type of decay is also known as root decay.

Dental caries, also known as tooth decay or cavity, is a disease wherein bacterial processes damage hard tooth structure (enamel, dentin and cementum). These tissues progressively break down, producing dental cavities (holes in the teeth). Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacilli. If left untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, death. Today, caries remains one of the most common diseases throughout the world. Cariology is the study of dental caries.

The presentation of caries is highly variable; however, the risk factors and stages of development are similar. Initially, it may appear as a small chalky area that may eventually develop into a large cavitation. Sometimes caries may be directly visible, however other methods of detection such as radiographs are used for less visible areas of teeth and to judge the extent of destruction.

Tooth decay is caused by specific types of acid-producing bacteria that cause damage in the presence of fermentable carbohydrates such as sucrose, fructose, and glucose. The mineral content of teeth is sensitive to increases in acidity from the production of lactic acid. Specifically, a tooth (which is primarily mineral in content) is in a constant state of back-and-forth demineralization and remineralization between the tooth and surrounding saliva. When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization (i.e. there is a net loss of mineral structure on the tooth's surface). This results in the ensuing decay. Depending on the extent of tooth destruction, various treatments can be used to restore teeth to proper form, function, and aesthetics, but there is no known method to regenerate large amounts of tooth structure. Instead, dental health organizations advocate preventive and prophylactic measures, such as regular oral hygiene and dietary modifications, to avoid dental caries.

Classification

Caries can be classified by location, etiology, rate of progression, and affected hard tissues. These classification can be used to characterize a particular case of tooth decay in order to more accurately represent the condition to others and also indicate the severity of tooth destruction.

GV Black Classification of Restorations

Location

Generally, there are two types of caries when separated by location: caries found on smooth surfaces and caries found in pits and fissures. The location, development, and progression of smooth-surface caries differ from those of pit and fissure caries. G.V. Black created a classification system that is widely used and based on the location of the caries on the tooth. The original classification distinguished caries into five groups, indicated by the word, "Class", and a Roman numeral. Pit and fissure caries is indicated as Class I; smooth surface caries is further divided into Class II, Class III, Class IV, and Class V. A Class VI was added onto Black's classification and also represents a smooth-surface carious lesion.

The pits and fissures of teeth provide a location for caries formation.

Pit and fissure caries

Pits and fissures are anatomic landmarks on a tooth where the enamel folds inward. Fissures are formed during the development of grooves but the enamel in the area is not fully fused. As a result, a deep linear depression forms in the enamel's surface structure, which forms a location for dental caries to develop and flourish. Fissures are mostly located on the occlusal (chewing) surfaces of posterior teeth and palatal surfaces of maxillary anterior teeth. Pits are small, pinpoint depressions that are most commonly found at the ends or cross-sections of grooves. In particular, buccal pits are found on the facial surfaces of molars. For all types of pits and fissures, the deep infolding of enamel makes oral hygiene along these surfaces difficult, allowing dental caries to develop more commonly in these areas.

The occlusal surfaces of teeth represent 12.5% of all tooth surfaces but are the location of over 50% of all dental caries. Among children, pit and fissure caries represent 90% of all dental caries. Pit and fissure caries can sometimes be difficult to detect. As the decay progresses, caries in enamel nearest the surface of the tooth spreads gradually deeper. Once the caries reaches the dentin at the dentino-enamel junction, the decay quickly spreads laterally. Within the dentin, the decay follows a triangle pattern that points to the tooth's pulp. This pattern of decay is typically described as two triangles (one triangle in enamel, and another in dentin) with their bases conjoined to each other at the dentino-enamel junction (DEJ). This base-to-base pattern is typical of pit and fissure caries, unlike smooth-surface caries (where base and apex of the two triangles join).

Smooth-surface caries

There are three types of smooth-surface caries. Proximal caries, also called interproximal caries, form on the smooth surfaces between adjacent teeth. Root caries form on the root surfaces of teeth. The third type of smooth-surface caries occur on any other smooth tooth surface.

In this radiograph, the dark spots in the adjacent teeth show proximal caries.

Proximal caries are the most difficult type to detect. Frequently, this type of caries cannot be detected visually or manually with a dental explorer. Proximal caries form cervically (toward the roots of a tooth) just under the contact between two teeth. As a result, radiographs are needed for early discovery of proximal caries. Under Black's classification system, proximal caries on posterior teeth (premolars and molars) are designated as Class II caries. Proximal caries on anterior teeth (incisors and canines) are indicated as Class III if the incisal edge (chewing surface) is not included and Class IV if the incisal edge is included.

Root caries, which are sometimes described as a category of smooth-surfaces caries, are the third most common type of caries and usually occur when the root surfaces have been exposed due to gingival recession. When the gingiva is healthy, root caries is unlikely to develop because the root surfaces are not as accessible to bacterial plaque. The root surface is more vulnerable to the demineralization process than enamel because cementum begins to demineralize at 6.7 pH, which is higher than enamel's critical pH. Regardless, it is easier to arrest the progression of root caries than enamel caries because roots have a greater reuptake of fluoride than enamel. Root caries are most likely to be found on facial surfaces, then interproximal surfaces, then lingual surfaces. Mandibular molars are the most common location to find root caries, followed by mandibular premolars, maxillary anteriors, maxillary posteriors, and mandibular anteriors.

Lesions on other smooth surfaces of teeth are also possible. Since these occur in all smooth surface areas of enamel except for interproximal areas, these types of caries are easily detected and are associated with high levels of plaque and diets promoting caries formation. Under Black's classification system, caries near the gingiva on the facial or lingual surfaces is designated Class V. Class VI is reserved for caries confined to cusp tips on posterior teeth or incisal edges of anterior teeth.

Other general descriptions

Besides the two previously mentioned categories, carious lesions can be described further by their location on a particular surface of a tooth. Caries on a tooth's surface that are nearest the cheeks or lips are called "facial caries", and caries on surfaces facing the tongue are known as "lingual caries". Facial caries can be subdivided into buccal (when found on the surfaces of posterior teeth nearest the cheeks) and labial (when found on the surfaces of anterior teeth nearest the lips). Lingual caries can also be described as palatal when found on the lingual surfaces of maxillary teeth because they are located beside the hard palate.

Caries near a tooth's cervix—the location where the crown of a tooth and its roots meet—are referred to as cervical caries. Occlusal caries are found on the chewing surfaces of posterior teeth. Incisal caries are caries found on the chewing surfaces of anterior teeth. Caries can also be described as "mesial" or "distal." Mesial signifies a location on a tooth closer to the median line of the face, which is located on a vertical axis between the eyes, down the nose, and between the contact of the central incisors. Locations on a tooth further away from the median line are described as distal.

Etiology

Rampant caries.

In some instances, caries are described in other ways that might indicate the cause. "Baby bottle caries", "early childhood caries", or "baby bottle tooth decay" is a pattern of decay found in young children with their deciduous (baby) teeth. The teeth most likely affected are the maxillary anterior teeth, but all teeth can be affected. The name for this type of caries comes from the fact that the decay usually is a result of allowing children to fall asleep with sweetened liquids in their bottles or feeding children sweetened liquids multiple times during the day. Another pattern of decay is "rampant caries", which signifies advanced or severe decay on multiple surfaces of many teeth. Rampant caries may be seen in individuals with xerostomia, poor oral hygiene, stimulant use (due to drug-induced dry mouth), and/or large sugar intake. If rampant caries is a result of previous radiation to the head and neck, it may be described as radiation-induced caries. Problems can also be caused by the self destruction of roots and whole tooth resorption when new teeth erupt or later from unknown causes.

Rate of progression

Temporal descriptions can be applied to caries to indicate the progression rate and previous history. "Acute" signifies a quickly developing condition, whereas "chronic" describes a condition which has taken an extended time to develop where thousands of meals and snacks, many causing some acid demineralisation that is not remineralised and eventually results in cavities.

Recurrent caries, also described as secondary, are caries that appears at a location with a previous history of caries. This is frequently found on the margins of fillings and other dental restorations. On the other hand, incipient caries describes decay at a location that has not experienced previous decay. Arrested caries describes a lesion on a tooth which was previously demineralized but was remineralized before causing a cavitation.

Affected hard tissue

Depending on which hard tissues are affected, it is possible to describe caries as involving enamel, dentin, or cementum. Early in its development, caries may affect only enamel. Once the extent of decay reaches the deeper layer of dentin, "dentinal caries" is used. Since cementum is the hard tissue that covers the roots of teeth, it is not often affected by decay unless the roots of teeth are exposed to the mouth. Although the term "cementum caries" may be used to describe the decay on roots of teeth, very rarely does caries affect the cementum alone. Roots have a very thin layer of cementum over a large layer of dentin, and thus most caries affecting cementum also affects dentin.

Signs and symptoms

Dental explorer used for caries diagnosis.

A person experiencing caries may not be aware of the disease. The earliest sign of a new carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an area of demineralization of enamel. This is referred to as incipient decay. As the lesion continues to demineralize, it can turn brown but will eventually turn into a cavitation ("cavity"). Before the cavity forms, the process is reversible, but once a cavity forms, the lost tooth structure cannot be regenerated. A lesion which appears brown and shiny suggests dental caries was once present but the demineralization process has stopped, leaving a stain. A brown spot which is dull in appearance is probably a sign of active caries.

As the enamel and dentin are destroyed, the cavity becomes more noticeable. The affected areas of the tooth change color and become soft to the touch. Once the decay passes through enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed and cause the tooth to hurt. The pain may worsen with exposure to heat, cold, or sweet foods and drinks. Dental caries can also cause bad breath and foul tastes. In highly progressed cases, infection can spread from the tooth to the surrounding soft tissues. Complications such as cavernous sinus thrombosis and Ludwig's angina can be life-threatening.

Causes

There are four main criteria required for caries formation: a tooth surface (enamel or dentin); caries-causing bacteria; fermentable carbohydrates (such as sucrose); and time. The caries process does not have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the shape of their teeth, oral hygiene habits, and the buffering capacity of their saliva. Dental caries can occur on any surface of a tooth which is exposed to the oral cavity, but not the structures which are retained within the bone.

Teeth

There are certain diseases and disorders affecting teeth which may leave an individual at a greater risk for caries. Amelogenesis imperfecta, which occurs between 1 in 718 and 1 in 14,000 individuals, is a disease in which the enamel does not fully form or forms in insufficient amounts and can fall off a tooth. In both cases, teeth may be left more vulnerable to decay because the enamel is not able to protect the tooth.

In most people, disorders or diseases affecting teeth are not the primary cause of dental caries. Ninety-six percent of tooth enamel is composed of minerals. These minerals, especially hydroxyapatite, will become soluble when exposed to acidic environments. Enamel begins to demineralize at a pH of 5.5. Dentin and cementum are more susceptible to caries than enamel because they have lower mineral content. Thus, when root surfaces of teeth are exposed from gingival recession or periodontal disease, caries can develop more readily. Even in a healthy oral environment, however, the tooth is susceptible to dental caries.

The anatomy of teeth may affect the likelihood of caries formation. Where the deep grooves of teeth are more numerous and exaggerated, pit and fissure caries are more likely to develop. Also, caries are more likely to develop when food is trapped between teeth.

A gram stain image of Streptococcus mutans.

Bacteria

The mouth contains a wide variety of oral bacteria, but only a few specific species of bacteria are believed to cause dental caries: Streptococcus mutans and Lactobacilli among them. Lactobacillus acidophilus, Actinomyces viscosus, Nocardia spp., and Streptococcus mutans are most closely associated with caries, particularly root caries. Bacteria collect around the teeth and gums in a sticky, creamy-coloured mass called plaque, which serves as a biofilm. Some sites collect plaque more commonly than others. The grooves on the biting surfaces of molar and premolar teeth provide microscopic retention, as does the point of contact between teeth. Plaque may also collect along the gingiva.

Fermentable carbohydrates

Bacteria in a person's mouth convert glucose, fructose, and most commonly sucrose (table sugar) into acids such as lactic acid through a glycolytic process called fermentation. If left in contact with the tooth, these acids may cause demineralization, which is the dissolution of its mineral content. The process is dynamic, however, as remineralization can also occur if the acid is neutralized by saliva or mouthwash. Fluoride toothpaste or dental varnish may aid remineralization. If demineralization continues over time, enough mineral content may be lost so that the soft organic material left behind disintegrates, forming a cavity or hole. The impact such sugars have on the progress of dental caries is called its cariogenicity. Sucrose, although a bound glucose and fructose unit, is in fact more cariogenic than a mixture of equal parts of glucose and fructose. This is due to the bacteria utilising the energy in the saccharide bond between the glucose and fructose subunits.

Time

The frequency of which teeth are exposed to cariogenic (acidic) environments affects the likelihood of caries development. After meals or snacks, the bacteria in the mouth metabolize sugar, resulting in an acidic by-product which decreases pH. As time progresses, the pH returns to normal due to the buffering capacity of saliva and the dissolved mineral content of tooth surfaces. During every exposure to the acidic environment, portions of the inorganic mineral content at the surface of teeth dissolves and can remain dissolved for 2 hours. Since teeth are vulnerable during these acidic periods, the development of dental caries relies heavily on the frequency of acid exposure.

The carious process can begin within days of a tooth erupting into the mouth if the diet is sufficiently rich in suitable carbohydrates. Evidence suggests that the introduction of fluoride treatments have slowed the process. Proximal caries take an average of four years to pass through enamel in permanent teeth. Because the cementum enveloping the root surface is not nearly as durable as the enamel encasing the crown, root caries tends to progress much more rapidly than decay on other surfaces. The progression and loss of mineralization on the root surface is 2.5 times faster than caries in enamel. In very severe cases where oral hygiene is very poor and where the diet is very rich in fermentable carbohydrates, caries may cause cavities within months of tooth eruption. This can occur, for example, when children continuously drink sugary drinks from baby bottles.

Other risk factors

Reduced saliva is associated with increased caries since the buffering capability of saliva is not present to counterbalance the acidic environment created by certain foods. As a result, medical conditions that reduce the amount of saliva produced by salivary glands, particularly the submandibular gland and parotid gland, are likely to lead to widespread tooth decay. Examples include Sjögren's syndrome, diabetes mellitus, diabetes insipidus, and sarcoidosis. Medications, such as antihistamines and antidepressants, can also impair salivary flow. Moreover, sixty-three percent of the most commonly prescribed medications in the United States list dry mouth as a known side effect. Radiation therapy of the head and neck may also damage the cells in salivary glands, increasing the likelihood of caries formation.

The use of tobacco may also increase the risk for caries formation. Some brands of smokeless tobacco contain high sugar content, increasing susceptibility to caries. Tobacco use is a significant risk factor for periodontal disease, which can cause the gingiva to recede. As the gingiva loses attachment to the teeth, the root surface becomes more visible in the mouth. If this occurs, root caries is a concern since the cementum covering the roots of teeth is more easily demineralized by acids than enamel. Currently, there is not enough evidence to support a causal relationship between smoking and coronal caries, but evidence does suggest a relationship between smoking and root-surface caries.

Pathophysiology

The progression of pit and fissure caries resembles two triangles with their bases meeting along the junction of enamel and dentin.

Enamel

Enamel is a highly mineralized acellular tissue, and caries act upon it through a chemical process brought on by the acidic environment produced by bacteria. As the bacteria consume the sugar and use it for their own energy, they produce lactic acid. The effects of this process include the demineralization of crystals in the enamel, caused by acids, over time until the bacteria physically penetrate the dentin. Enamel rods, which are the basic unit of the enamel structure, run perpendicularly from the surface of the tooth to the dentin. Since demineralization of enamel by caries generally follows the direction of the enamel rods, the different triangular patterns between pit and fissure and smooth-surface caries develop in the enamel because the orientation of enamel rods are different in the two areas of the tooth .

As the enamel loses minerals , and dental caries progress, they develop several distinct zones, visible under a light microscope. From the deepest layer of the enamel to the enamel surface, the identified areas are the: translucent zone, dark zones, body of the lesion, and surface zone. The translucent zone is the first visible sign of caries and coincides with a 1-2% loss of minerals. A slight remineralization of enamel occurs in the dark zone, which serves as an example of how the development of dental caries is an active process with alternating changes. The area of greatest demineralization and destruction is in the body of the lesion itself. The surface zone remains relatively mineralized and is present until the loss of tooth structure results in a cavitation.

Dentin

Unlike enamel, the dentin reacts to the progression of dental caries. After tooth formation, the ameloblasts, which produce enamel, are destroyed once enamel formation is complete and thus cannot later regenerate enamel after its destruction. On the other hand, dentin is produced continuously throughout life by odontoblasts, which reside at the border between the pulp and dentin. Since odontoblasts are present, a stimulus, such as caries, can trigger a biologic response. These defense mechanisms include the formation of sclerotic and tertiary dentin.

In dentin from the deepest layer to the enamel, the distinct areas affected by caries are the translucent zone, the zone of bacterial penetration, and the zone of destruction. The translucent zone represents the advancing front of the carious process and is where the initial demineralization begins. The zones of bacterial penetration and destruction are the locations of invading bacteria and ultimately the decomposition of dentin.

The faster spread of caries through dentin creates this triangular appearance in smooth surface caries.

Sclerotic dentin

The structure of dentin is an arrangement of microscopic channels, called dentinal tubules, which radiate outward from the pulp chamber to the exterior cementum or enamel border. The diameter of the dentinal tubules is largest near the pulp (about 2.5 μm) and smallest (about 900 nm) at the junction of dentin and enamel. The carious process continues through the dentinal tubules, which are responsible for the triangular patterns resulting from the progression of caries deep into the tooth. The tubules also allow caries to progress faster.

In response, the fluid inside the tubules bring immunoglobulins from the immune system to fight the bacterial infection. At the same time, there is an increase of mineralization of the surrounding tubules. This results in a constriction of the tubules, which is an attempt to slow the bacterial progression. In addition, as the acid from the bacteria demineralizes the hydroxyapatite crystals, calcium and phosphorus are released, allowing for the precipitation of more crystals which fall deeper into the dentinal tubule. These crystals form a barrier and slow the advancement of caries. After these protective responses, the dentin is considered sclerotic.

Fluids within dentinal tubules are believed to be the mechanism by which pain receptors are triggered within the pulp of the tooth. Since sclerotic dentin prevents the passage of such fluids, pain that would otherwise serve as a warning of the invading bacteria may not develop at first. Consequently, dental caries may progress for a long period of time without any sensitivity of the tooth, allowing for greater loss of tooth structure.

Tertiary dentin

In response to dental caries, there may the production of more dentin toward the direction of the pulp. This new dentin is referred to as tertiary dentin. Tertiary dentin is produced to protect the pulp for as long as possible from the advancing bacteria. As more tertiary dentin is produced, the size of the pulp decreases. This type of dentin has been subdivided according to the presence or absence of the original odontoblasts. If the odontoblasts survive long enough to react to the dental caries, then the dentin produced is called "reactionary" dentin. If the odontoblasts are killed, the dentin produced is called "reparative" dentin.

In the case of reparative dentin, other cells are needed to assume the role of the destroyed odontoblasts. Growth factors, especially TGF-β, are thought to initiate the production of reparative dentin by fibroblasts and mesenchymal cells of the pulp. Reparative dentin is produced at an average of 1.5 μm/day, but can be increased to 3.5 μm/day. The resulting dentin contains irregularly-shaped dentinal tubules which may not line up with existing dentinal tubules. This diminishes the ability for dental caries to progress within the dentinal tubules.

Diagnosis

(A) A small spot of decay visible on the surface of a tooth. (B) The radiograph reveals an extensive region of demineralization within the dentin (arrows). (C) A hole is discovered on the side of the tooth at the beginning of decay removal. (D) All decay removed.

Primary diagnosis involves inspection of all visible tooth surfaces using a good light source, dental mirror and explorer. Dental radiographs (X-rays) may show dental caries before it is otherwise visible, particularly caries between the teeth. Large dental caries are often apparent to the naked eye, but smaller lesions can be difficult to identify. Visual and tactile inspection along with radiographs are employed frequently among dentists, particularly to diagnose pit and fissure caries. Early, uncavitated caries is often diagnosed by blowing air across the suspect surface, which removes moisture and changes the optical properties of the unmineralized enamel.

Some dental researchers have cautioned against the use of dental explorers to find caries. In cases where a small area of tooth has begun demineralizing but has not yet cavitated, the pressure from the dental explorer could cause a cavity. Since the carious process is reversible before a cavity is present, it may be possible to arrest the caries with fluoride and remineralize the tooth surface. When a cavity is present, a restoration will be needed to replace the lost tooth structure.

At times, pit and fissure caries may be difficult to detect. Bacteria can penetrate the enamel to reach dentin, but then the outer surface may remineralize, especially if fluoride is present. These caries, sometimes referred to as "hidden caries", will still be visible on x-ray radiographs, but visual examination of the tooth would show the enamel intact or minimally perforated.

Treatment

An amalgam used as a restorative material in a tooth.

Destroyed tooth structure does not fully regenerate, although remineralization of very small carious lesions may occur if dental hygiene is kept at optimal level. For the small lesions, topical fluoride is sometimes used to encourage remineralization. For larger lesions, the progression of dental caries can be stopped by treatment. The goal of treatment is to preserve tooth structures and prevent further destruction of the tooth.

Generally, early treatment is less painful and less expensive than treatment of extensive decay. Anesthetics — local, nitrous oxide ("laughing gas"), or other prescription medications — may be required in some cases to relieve pain during or following treatment or to relieve anxiety during treatment. A dental handpiece ("drill") is used to remove large portions of decayed material from a tooth. A spoon is a dental instrument used to remove decay carefully and is sometimes employed when the decay in dentin reaches near the pulp. Once the decay is removed, the missing tooth structure requires a dental restoration of some sort to return the tooth to functionality and aesthetic condition.

Restorative materials include dental amalgam, composite resin, porcelain, and gold. Composite resin and porcelain can be made to match the color of a patient's natural teeth and are thus used more frequently when aesthetics are a concern. Composite restorations are not as strong as dental amalgam and gold; some dentists consider the latter as the only advisable restoration for posterior areas where chewing forces are great. When the decay is too extensive, there may not be enough tooth structure remaining to allow a restorative material to be placed within the tooth. Thus, a crown may be needed. This restoration appears similar to a cap and is fitted over the remainder of the natural crown of the tooth. Crowns are often made of gold, porcelain, or porcelain fused to metal.

A tooth with extensive caries eventually requiring extraction.

In certain cases, endodontic therapy may be necessary for the restoration of a tooth. Endodontic therapy, also known as a "root canal", is recommended if the pulp in a tooth dies from infection by decay-causing bacteria or from trauma. During a root canal, the pulp of the tooth, including the nerve and vascular tissues, is removed along with decayed portions of the tooth. The canals are instrumented with endodontic files to clean and shape them, and they are then usually filled with a rubber-like material called gutta percha. The tooth is filled and a crown can be placed. Upon completion of a root canal, the tooth is now non-vital, as it is devoid of any living tissue.

An extraction can also serve as treatment for dental caries. The removal of the decayed tooth is performed if the tooth is too far destroyed from the decay process to effectively restore the tooth. Extractions are sometimes considered if the tooth lacks an opposing tooth or will probably cause further problems in the future, as may be the case for wisdom teeth. Extractions may also be preferred by patients unable or unwilling to undergo the expense or difficulties in restoring the tooth.

Prevention

Toothbrushes are commonly used to clean teeth.

Oral hygiene

Personal hygiene care consists of proper brushing and flossing daily. The purpose of oral hygiene is to minimize any etiologic agents of disease in the mouth. The primary focus of brushing and flossing is to remove and prevent the formation of plaque. Plaque consists mostly of bacteria. As the amount of bacterial plaque increases, the tooth is more vulnerable to dental caries when carbohydrates in the food are left on teeth after every meal or snack. A toothbrush can be used to remove plaque on accessible surfaces, but not between teeth or inside pits and fissures on chewing surfaces. When used correctly, dental floss removes plaque from areas which could otherwise develop proximal caries. Other adjunct hygiene aids include interdental brushes, water picks, and mouthwashes.

However oral hygiene is probably more effective at preventing gum disease than tooth decay. The brush and fluoride toothpaste have no access inside pits and fissures, where chewing forces food to be trapped. It is here that resident plaque bacteria change any carbohydrate to acid that demineralises teeth inside pits and fissures, causing over 80% of cavities. (Occlusal caries accounts for between 80 and 90 percent of caries in children (Weintraub, 2001). The teeth at highest risk for carious lesions are the first and second permanent molars.)

Chewing fibre like celery after eating forces saliva inside pits and fissures to dilute any carbohydrate like sugar in trapped food, neutralise acid and remineralise demineralised tooth and should be part of every day personal tooth care to prevent tooth decay.

Professional hygiene care consists of regular dental examinations and cleanings. Sometimes, complete plaque removal is difficult, and a dentist or dental hygienist may be needed. Along with oral hygiene, radiographs may be taken at dental visits to detect possible dental caries development in high risk areas of the mouth.

Dietary modification

For dental health, frequency of sugar intake is more important than the amount of sugar consumed. In the presence of sugar and other carbohydrates, bacteria in the mouth produce acids which can demineralize enamel, dentin, and cementum. The more frequently teeth are exposed to this environment, the more likely dental caries are to occur. Therefore, minimizing snacking is recommended, since snacking creates a continual supply of nutrition for acid-creating bacteria in the mouth. Also, chewy and sticky foods (such as dried fruit or candy) tend to adhere to teeth longer, and consequently are best eaten as part of a meal. Brushing the teeth after meals is recommended. For children, the American Dental Association and the European Academy of Paediatric Dentistry recommend limiting the frequency of consumption of drinks with sugar, and not giving baby bottles to infants during sleep. Mothers are also recommended to avoid sharing utensils and cups with their infants to prevent transferring bacteria from the mother's mouth.

It has been found that milk and certain kinds of cheese like cheddar can help counter tooth decay if eaten soon after the consumption of foods potentially harmful to teeth. Also, chewing gum containing xylitol (a sugar alcohol) is widely used to protect teeth in some countries, being especially popular in the Finnish candy industry. Xylitol's effect on reducing plaque is probably due to bacteria's inability to utilize it like other sugars. Chewing and stimulation of flavour receptors on the tongue are also known to increase the production and release of saliva, which contains natural buffers to prevent the lowering of pH in the mouth to the point where enamel may become demineralised.

Common dentistry trays used to deliver fluoride.

Other preventive measures

The use of dental sealants is a means of prevention. A sealant is a thin plastic-like coating applied to the chewing surfaces of the molars. This coating prevents food being trapped inside pits and fissures in grooves under chewing pressure so resident plaque bacteria are deprived of carbohydrate that they change to acid demineralisation and thus prevents the formation of pit and fissure caries, the most common form of dental caries. Sealants are usually applied on the teeth of children, shortly after the molars erupt. Older people may also benefit from the use of tooth sealants, but their dental history and likelihood of caries formation are usually taken into consideration.

Calcium, as found in milk and green vegetables are often recommended to protect against dental caries. It has been demonstrated that Calcium and fluoride supplements decrease the incidence of dental caries. Fluoride helps prevent decay of a tooth by binding to the hydroxyapatite crystals in enamel. The incorporated Calcium makes enamel more resistant to demineralization and, thus, resistant to decay. Topical fluoride is also recommended to protect the surface of the teeth. This may include a fluoride toothpaste or mouthwash. Many dentists include application of topical fluoride solutions as part of routine visits.

Furthermore, recent research shows that low intensity laser radiation of argon ion lasers may prevent the susceptibility for enamel caries and white spot lesions. Also, as bacteria are a major factor contributing to poor oral health, there is currently research to find a vaccine for dental caries. As of 2004, such a vaccine has been successfully tested on animals, and is in clinical trials for humans as of May 2006.

Epidemiology

Worldwide, most children and an estimated ninety percent of adults have experienced caries, with the disease most prevalent in Asian and Latin American countries and least prevalent in African countries. In the United States, dental caries is the most common chronic childhood disease, being at least five times more common than asthma. It is the primary pathological cause of tooth loss in children. Between 29% and 59% of adults over the age of fifty experience caries.

The number of cases has decreased in some developed countries, and this decline is usually attributed to increasingly better oral hygiene practices and preventive measures such as fluoride treatment. Nonetheless, countries that have experienced an overall decrease in cases of tooth decay continue to have a disparity in the distribution of the disease. Among children in the United States and Europe, twenty percent of the population endures sixty to eighty percent of cases of dental caries. A similarly skewed distribution of the disease is found throughout the world with some children having none or very few caries and others having a high number. Australia, Nepal, and Sweden have a low incidence of cases of dental caries among children, whereas cases are more numerous in Costa Rica and Slovakia.

The classic "DMF" (decay/missing/filled) index is one of the most common methods for assessing caries prevalence as well as dental treatment needs among populations. This index is based on in-field clinical examination of individuals by using a probe, mirror and cotton rolls. Because the DMF index is done without X-ray imaging, it underestimates real caries prevalence and treatment needs.

History

An image from 1300s (A.D.) England depicting a dentist extracting a tooth with forceps.

There is a long history of dental caries. Over a million years ago, hominids such as Australopithecus suffered from cavities. The largest increases in the prevalence of caries have been associated with dietary changes. Archaeological evidence shows that tooth decay is an ancient disease dating far into prehistory. Skulls dating from a million years ago through the neolithic period show signs of caries, excepting those from the Paleolithic and Mesolithic ages. The increase of caries during the neolithic period may be attributed to the increase of plant foods containing carbohydrates. The beginning of rice cultivation in South Asia is also believed to have caused an increase in caries.

A Sumerian text from 5000 BC describes a "tooth worm" as the cause of caries. Evidence of this belief has also been found in India, Egypt, Japan, and China.

Unearthed ancient skulls show evidence of primitive dental work. In Pakistan, teeth dating from around 5500 BC to 7000 BC show nearly perfect holes from primitive dental drills. The Ebers Papyrus, an Egyptian text from 1550 BC, mentions diseases of teeth. During the Sargonid dynasty of Assyria during 668 to 626 BC, writings from the king's physician specify the need to extract a tooth due to spreading inflammation. In the Roman Empire, wider consumption of cooked foods led to a small increase in caries prevalence. The Greco-Roman civilization, in addition to the Egyptian, had treatments for pain resulting from caries.

The rate of caries remained low through the Bronze and Iron ages, but sharply increased during the Medieval period. Periodic increases in caries prevalence had been small in comparison to the 1000 AD increase, when sugar cane became more accessible to the Western world. Treatment consisted mainly of herbal remedies and charms, but sometimes also included bloodletting. The barber surgeons of the time provided services that included tooth extractions. Learning their training from apprenticeships, these health providers were quite successful in ending tooth pain and likely prevented systemic spread of infections in many cases. Among Roman Catholics, prayers to Saint Apollonia, the patroness of dentistry, were meant to heal pain derived from tooth infection.

There is also evidence of caries increase in North American Indians after contact with colonizing Europeans. Before colonization, North American Indians subsisted on hunter-gatherer diets, but afterwards there was a greater reliance on maize agriculture, which made these groups more susceptible to caries.

In the medieval Islamic world, Muslim physicians such as al-Gazzar and Avicenna (in The Canon of Medicine) provided the earliest known treatments for caries, though they also believed that it was caused by tooth worms as the ancients had. This was eventually proven false in 1200 by another Muslim dentist named Gaubari, who in his Book of the Elite concerning the unmasking of mysteries and tearing of veils, was the first to reject the idea of caries being caused by tooth worms, and he stated that tooth worms in fact do not even exist. The theory of the tooth worm was thus no longer accepted in the Islamic medical community from the 13th century onwards.

During the European Age of Enlightenment, the belief that a "tooth worm" caused caries was also no longer accepted in the European medical community. Pierre Fauchard, known as the father of modern dentistry, was one of the first to reject the idea that worms caused tooth decay and noted that sugar was detrimental to the teeth and gingiva. In 1850, another sharp increase in the prevalence of caries occurred and is believed to be a result of widespread diet changes. Prior to this time, cervical caries was the most frequent type of caries, but increased availability of sugar cane, refined flour, bread, and sweetened tea corresponded with a greater number of pit and fissure caries.

In the 1890s, W.D. Miller conducted a series of studies that led him to propose an explanation for dental caries that was influential for current theories. He found that bacteria inhabited the mouth and that they produced acids which dissolved tooth structures when in the presence of fermentable carbohydrates. This explanation is known as the chemoparasitic caries theory. Miller's contribution, along with the research on plaque by G.V. Black and J.L. Williams, served as the foundation for the current explanation of the etiology of caries. Several of the specific strains of bacteria were identified in 1921 by Fernando E. Rodriguez Vargas.

Gingivitis

2009-09-01T05:51:00.000-07:00

Gingivitis ("inflammation of the gums") (gingiva) around the teeth is a general term for gingival diseases affecting the gingiva (gums). As generally used, the term gingivitis refers to gingival inflammation induced by bacterial biofilms (also called plaque) adherent to tooth surfaces.

Causes

Gingivitis can be defined as inflammation of the gingival tissue without loss of tooth attachment (i.e.periodontal ligament). Gingivitis is an irritation of the gums. It is usually caused by bacterial plaque that accumulates in the small gaps between the gums and the teeth and by calculus (tartar) that forms on the teeth. These accumulations may be tiny, even microscopic, but the bacteria in them produce foreign chemicals and toxins that cause inflammation of the gums around the teeth. This inflammation can, over the years, cause deep pockets between the teeth and gums and loss of bone around teeth—an effect otherwise known as periodontitis. Since the bone in the jaws holds the teeth into the jaws, the loss of bone from periodontitis can cause teeth over the years to become loose and eventually to fall out or need to be extracted because of acute infection.

Proper maintenance (varying from "regular cleanings" to periodontal maintenance or scaling and root planing) above and below the gum line, done professionally by a dental hygienist or dentist, disrupts this plaque biofilm and removes plaque retentive calculus (tartar) to help remove the etiology of inflammation. Once cleaned, plaque will begin to grow on the teeth within hours. However, it takes approximately 3 months for the pathogenic type of bacteria (typically gram negative anaerobes and spirochetes) to grow back into deep pockets and restart the inflammatory process. Calculus (tartar) may start to reform within 24 hours. Ideally, scientific studies show that all people with deep periodontal pockets (greater than 5 mm) should have the pockets between their teeth and gums cleaned by a dental hygienist or dentist every 3–4 months.

People with a healthy periodontium (gingiva, alveolar bone and periodontal ligaments) or people with gingivitis may only require periodontal debridement every 6 months. However, many dental professionals only recommend debridement (cleanings) every 6 months, because this has been the standard advice for decades, and because the benefits of regular debridement (cleanings) are too subtle for many patients to notice without regular education from the dental hygienist or dentist. If the inflammation in the gums becomes especially well-developed, it can invade the gums and allow tiny amounts of bacteria and bacterial toxins to enter the bloodstream. The patient may not be able to notice this, but studies suggest this can result in a generalized increase in inflammation in the body and/or cause possible long term heart problems. Periodontitis has also been linked to diabetes, arteriosclerosis, osteoporosis, pancreatic cancer and pre-term low birth weight babies.

Sometimes, the inflammation of the gingiva can suddenly amplify, such as to cause a disease called Acute Necrotizing Ulcerative Gingitivitis (ANUG), otherwise known as "trench mouth." The etiology of ANUG is the overgrowth of a particular type of pathogenic bacteria (fusiform-spirochete variety) but risk factors such as stress, poor nutrition and a compromised immune system can exacerbate the infection. This results in the breath being extremely bad-smelling, and the gums feeling considerable pain and degeneration of the periodontium rapidly occurs. This can be successfully treated with a 1-week course of Metronidazole antibiotic, followed by a deep cleaning of the gums by a dental hygienist or dentist and reduction of risk factors such as stress.

When the teeth are not cleaned properly by regular brushing and flossing, bacterial plaque accumulates, and becomes mineralized by calcium and other minerals in the saliva transforming it into a hard material called calculus (tartar) which harbors bacteria and irritates the gingiva (gums). Also, as the bacterial plaque biofilm becomes thicker this creates an anoxygenic environment which allows more pathogenic bacteria to flourish and release toxins and cause gingival inflammation. Pregnancy, uncontrolled diabetes mellitus and the onset of puberty increase the risk of gingivitis, due to hormonal changes that may increase the susceptibility of the gums or alter the composition of the dentogingival microflora. The risk of gingivitis is increased by misaligned teeth, the rough edges of fillings, and ill fitting or unclean dentures, bridges, and crowns. This is due to their plaque retentive properties. Birth control pills, and ingestion of heavy metals such as lead and bismuth may also cause gingivitis.

Symptoms

The symptoms of gingivitis are as follows:

Swollen gums
Mouth sores
Bright-red, or purple gums
Shiny gums
Swollen gums that emit pus
Severe oral odor
Gums that are tender, or painful to the touch.
Gums that bleed easily, even with gentle brushing, and especially when flossing.
Gums that itch with varying degrees of severity.

Treatment

Prevention

OTC anti-gingivitis mouthwash containing chlorhexidine from Mexico.

Gingivitis can be prevented through regular oral hygiene that includes daily brushing and flossing. Mouthwash or Hydrogen Peroxide can be helpful, usually using peroxide or saline solutions (water and salt), alcohol or chlorhexidine. Try one cap of Hydrogen peroxide with two caps of water as an inexpensive treatment. Rinse, do not swallow, spit and wash your mouth out with water. Rigorous plaque control programs along with periodontal scaling and curettage also have proved to be helpful, although according to the American Dental Association, periodontal scaling and root planing are considered as a treatment to periodontal disease, not as a preventive treatment for periodontal disease.
If the ADA recognized the need for gum treatments with a set frequency for the treatment and prevention of periodontal disease then medical insurance companies would be required to pay. Gum disease eventually follows and your teeth fall out since people require treatments often.

In many countries, such as the United States, mouthwashes containing chlorhexidine are available only by prescription.

Researchers analyzed government data on calcium consumption and periodontal disease indicators in nearly 13,000 U.S. adults. They found that men and women who had calcium intakes of fewer than 500 milligrams, or about half the recommended dietary allowance, were almost twice as likely to have gum disease, as measured by the loss of attachment of the gums from the teeth. The association was particularly evident for people in their 20s and 30s.

Research says the connection between calcium and gum disease is likely due to calcium’s role in building density in the alveolar bone that supports the teeth.

Preventing gum disease may also benefit a healthy heart. According to physicians with The Institute for Good Medicine at The Pennsylvania Medical Society, good oral health can reduce risk of cardiac events. Poor oral health can lead to infections that can travel within the bloodstream.

Complications

Recurrence of gingivitis
Periodontitis
Infection or abscess of the gingiva or the jaw bones
Trench mouth (bacterial infection and ulceration of the gums)

Periodontitis

2009-09-01T05:35:00.000-07:00

Periodontitis (peri = around, odont = tooth, -itis = inflammation) refers to a number of inflammatory diseases affecting the periodontium — that is, the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by bacteria that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these bacteria. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe and radiographs by visual analysis, to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" and "periodontics".

Chronic Periodontitis, the most common form of the disease, progresses relatively slowly and typically becomes clinically evident in adulthood. Aggressive Periodontitis is a rarer form, but as its name implies, progresses more rapidly and becomes clinically evident in adolescence. Although the different forms of periodontitis are all caused by bacterial infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly-controlled diabetes, and inherited (genetic) susceptibility.

Epidemiology

Periodontitis is very common, and is widely regarded as the second most common disease worldwide, after dental decay, and in the United States has a prevalence of 30-50% of the population, but only about 10% have severe forms.

Studies found an association between ethnic origin and periodontal diseases. In the USA, African-Americans have a higher prevalence of periodontal disease compared with Latin individuals as well as non-Hispanic people of European descent. In Israeli population, individuals of Yemenite, North-African, Asian, or Mediterranean origin have higher prevalence of periodontal disease than individuals from European descent. This could be attributed to genetic predisposition as well as social-cultural-behavioral differences (eg., smoking, oral hygiene, access to dental treatment) between populations.

Etiology

Periodontitis is an inflammation of the periodontium—the tissues that support the teeth. The periodontium consists of four tissues:

the gingiva, or gum tissue;
the cementum, or outer layer of the roots of teeth;
the alveolar bone, or the bony sockets into which the teeth are anchored;
the periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.

This X-ray film displays two lone-standing mandibular teeth, the lower left first premolar and canine, exhibiting severe bone loss of 30-50%. Widening of the PDL surrounding the premolar is due to secondary occlusal trauma.

The primary etiology, or cause, of gingivitis is poor oral hygiene which leads to the accumulation of a bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. New FDA-approved finger nick tests are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes. In some people, gingivitis progresses to periodontitis - with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival bacteria (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology would be those things that, by definition, cause plaque accumulation, such as restoration overhangs and root proximity.

The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed "overhangs", and serve to trap plaque, potentially leading to localized periodontitis.

If left undisturbed, bacterial plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the bacterial plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.

Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial insult is mainly determined by genetics; however, immune development may play some role in susceptibility.

Signs and symptoms

In the early stages, periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment. Symptoms may include the following:

Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)
Gum swelling that recurs
Halitosis, or bad breath, and a persistent metallic taste in the mouth
Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)
Loose teeth, in the later stages (though this may occur for other reasons as well)

Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.

Prevention

Daily oral hygiene measures to prevent periodontal disease include:

Brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, to help disrupt the bacterial growth and formation of subgingival plaque.
Flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth, the third molar, in each quarter.
Using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis.
Using a 'soft' tooth brush to prevent damage to tooth enamel and sensitive gums.
Using periodontal trays to maintain dentist-prescribed medications at the source of the disease. The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the bacteria are found.
Regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.

Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), bacteria and plaque tend to grow back to pre-cleaning levels after about 3–4 months. Hence, in theory, cleanings every 3–4 months might be expected to also prevent the initial onset of periodontitis. However, analysis of published research has reported little evidence either to support this or the intervals at which this should occur. Instead, it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.

Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home as well as on the go. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.

A contributing cause may be low selenium in the diet: "Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold."

Treatment of established disease

This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the gingiva was originally (1-2 mm above the bone), prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.

The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.

Initial therapy: Removal of bacterial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called scaling and debridement. In the past, Root Planing was used (removal of cemental layer as well as calculus). This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth with reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.

Reevaluation: Multiple clinical studies have shown that non-surgical scaling and root planing is usually successful in periodontal pocket depths no greater than 4-5mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). It is necessary for the dentist or hygienist to perform a reevaluation 4–6 weeks after the initial scaling and root planing, to determine if the treatment was successful in reducing pocket depths and eliminating inflammation. It has been found that pocket depths which remain after initial therapy of greater than 5-6mm with bleeding upon probing are indicative of continued active disease and will very likely show further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.

Periodontal Surgery: If non-surgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgery may be needed to stop progressive bone loss and regenerate lost bone where possible. There are many surgical approaches used in treatment of advanced periodontitis, including open flap debridement, osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown that in moderate to advanced periodontitis surgically treated cases often have less further breakdown over time and when coupled with a regular post-treatment maintenance regimen are successful in nearly halting tooth loss in nearly 85% of patients (Kaldahl WB, Long-term evaluation of periodontal therapy: II. Incidence of sites breaking down. J Periodontol. 1996 Feb;67(2):103-8. and Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol. 1978 May;49(5):225-37.

Maintenance: Once successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of "periodontal maintenance" is required. This involves regular checkups and detailed cleanings every 3 months to prevent repopulation of periodontitis-causing bacteria, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs. Usually periodontal disease exist due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable

Assessment and prognosis

Dentists and dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.

According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.

Alternative Treatments

Periodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic bacteria that consume bone, gum and cementum (connective tissue) for food.

Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic bacteria colonies and is effective at reducing infections and inflammation when used daily. There are any number of potions and elixirs that are commercially available which are functionally equivalent to hydrogen peroxide; only at substantially higher cost. These treatments, however, do not address calculus formations, and are therefore short-lived, as anaerobic bacteria colonies quickly regenerate in and around calculus.

In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic and adhere to tooth surfaces via electrostatic attraction. Smaller, free floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified bacteria, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic bacteria, as does the top “diseased layer”.

Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus actually reducing the size of subgingival calculus formations.

To accomplish this, a sequestering agent solution comprised partly of Sodium Tripolyphosphate (STPP) and Sodium Fluoride (charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6mm. The patient delivered the solution using an oral irrigator, once a day, for sixty days. The results of this test were the successful elimination of all calculus formations studied. This test was conducted using a subgingival endoscopic camera (Perioscope) by an independent periodontist.

The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, with complete restoration of dental health being a collaborative effort between the patient and the dental professional.

Periodontitis in Dogs and Cats

Periodontal disease is the most common disease found in dogs and will affect more than 8 out of 10 dogs three years of age and older. The prevalence of periodontal disease in dogs increases with age but also decreases with increasing body weight; therefore, toy and miniature breeds are more severely affected. Systemic disease may develop because the gums are very vascular (have a good blood supply). Blood will carry these anaerobic bacteria via the blood stream where they are then filtered out by the kidneys and liver. Once removed by the liver or kidney they will then colonize in that particular organ developing microabscesses. The bacteria traveling through the blood may also attach to the heart valves resulting in vegetative endocarditis (infected heart valves). Additional diseases that may result from periodontitis includes chronic bronchitis and pulmonary fibrosis

Dental plaque

2009-09-01T05:26:00.001-07:00

Inadequate removal of plaque caused a build up of calculus (dark yellow color) near the gums on almost all the teeth.

Dental plaque is biofilm (usually colorless) that builds up on the teeth. If not removed regularly, it can lead to dental cavities (caries) or periodontal problems (such as gingivitis).

The microorganisms that form the biofilm are almost entirely bacteria (mainly Streptococcus mutans and anaerobes), with the composition varying by location in the mouth. Examples of such anaerobes include fusobacterium and Actinobacteria.

The microorganisms present in dental plaque are all naturally present in the oral cavity, and are normally harmless. However, failure to remove plaque by regular tooth brushing means that they are allowed to build up in a thick layer. Those microorganisms nearest the tooth surface convert to anaerobic respiration; it is in this state that they start to produce acids.

Acids released from dental plaque lead to demineralization of the adjacent tooth surface, and consequently to dental caries. Saliva is also unable to penetrate the build-up of plaque and thus cannot act to neutralize the acid produced by the bacteria and remineralize the tooth surface.
They also cause irritation of the gums around the teeth that could lead to gingivitis, periodontal disease and tooth loss.
Plaque build up can also become mineralized and form calculus (tartar).

Dental Plaque removal - Prevent tooth plaque build up

Dental plaque removal is essential for maintaining good oral health. It's easy to prevent plaque build up with proper care.
Follow these tips on how to remove plaque from teeth :

Brush thoroughly at least twice a day, with a fluoride toothpaste, to remove plaque from your teeth
Use dental floss daily to remove plaque from between your teeth and under your gum line, where your toothbrush may not reach
Check your teeth with plaque disclosing tablets to ensure removing tooth plaque.
Control your diet. Limit sugary or starchy foods, especially sticky snacks
Ask your dentist or dental hygienist if your plaque removal techniques are ok.
Visit your dentist regularly for professional cleanings and dental examinations

You must know that some treatments are not always covered by dental insurance plans. Learn how to check the terms and choose a dental insurance plan that will provide the best coverage for you and your family.

How to check for plaque - Dental Plaque Disclosing Tablets

Patients often believe that they brush correctly and deny to accept that they fail in tooth plaque removal, even if their dentist tells them about dental plaque formation when examining their teeth. Plaque on teeth is usually colorless and therefore can be difficult to see it and remove it during brushing.
Dental disclosing tablets and solutions stain the plaque build up on your teeth, allowing you to see how thoroughly you are brushing and flossing your teeth. They stain the bacteria making it easier to see where you have to brush again to remove dental plaque.
Plaque disclosing tablets and solutions are available without prescription from most pharmacies and they work by dyeing tooth plaque either blue or red. The active ingredients of disclosing products are usually dyes also used as food colourings. Erythrosine is the most common dental plaque dye in disclosing tablets and solutions.

How to use Dental Plaque Disclosing Tablets and Solutions

Use the plaque disclosing tablets or solution after brushing and flossing, following package instructions.
Put some dental disclosing solution in your mouth or chew a disclosing tablet and allow it to mix with your saliva.
Swish the mixture around in your mouth for about 30 seconds and then spit it out.
Gently rinse your mouth with water, and examine your teeth for plaque colored by the dye. Because the dye stains all bacteria the tongue and gums also may get dyed.
Check for stained (not properly cleaned) areas, usually the inside of the back teeth and behind the front teeth. Clean the stained areas to complete dental plaque removal. Next time you brush your teeth pay special attention to these areas.
Use disclosing products regularly until you find no more stained areas of dental plaque formation after you brush and floss. Recheck after some weeks.

Oral candidiasis

2009-09-01T05:26:00.000-07:00

Oral candidiasis (also known as "Thrush) is an infection of yeast fungi of the genus Candida on the mucous membranes of the mouth. It is frequently caused by Candida albicans, or less commonly by Candida glabrata or Candida tropicalis. Oral thrush may refer to candidiasis in the mouths of babies, while if occurring in the mouth or throat of adults it may also be termed candidosis or moniliasis.

Symptoms

Oral infections by Candida species usually appear as thick white or cream-coloured deposits on mucosal membranes. The infected mucosa of the mouth may appear inflamed (red and possibly slightly raised). In babies the condition is termed thrush. Adults may experience discomfort or burning.

Special risk groups

Newborn babies.
Diabetics with poorly controlled diabetes.
As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for treatment of lung conditions (e.g, Asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.
People with an immune deficiency (e.g. as a result of AIDS/HIV or chemotherapy treatment).
Women undergoing hormonal changes, like pregnancy or those on birth control pills.
People with fresh oral piercings coming into regular contact with yeast.^{[citation needed]}
Denture users.
Smokers.

Thrush and breastfeeding

Because of the increased use of antibiotics in laboring women to reduce the transmission of Group B streptococcal infection to the infant, thrush has become more prevalent. Symptoms include an oral rash in the infant's mouth, a diaper rash that does not heal with conventional diaper rash treatments and ointments, or burning, painful nipples of the breastfeeding mother.

The rash and pain experienced by the mother can range from severe to mild and may complicate breastfeeding. Treatments include good hygiene of the nipples; oral probiotics containing L. acidophilus; and over-the-counter antifungal cream containing nystatin, clotrimazole, or miconazole on the nipples. Some clinicians recommend washing the cream off before breastfeeding.

Treatment

Oral candidiasis on the tongue and soft palate.

Oral candidiasis can be treated with topical anti-fungal drugs, such as nystatin, miconazole or amphotericin B. Topical therapy is given as an oral suspension which is washed around the mouth and then swallowed by the patient.

Patients who are immunocompromised, either with HIV/AIDS or as a result of chemotherapy, may require systemic treatment with oral or intravenous administered anti-fungals.

Aphthous ulcer

2009-09-01T05:18:00.000-07:00

Mouth ulcer on the lower lip

An aphthous ulcer, also known as a canker sore, is a type of oral ulcer, which presents as a painful open sore inside the mouth or upper throat (including the uvula) caused by a break in the mucous membrane. The condition is also known as aphthous stomatitis, and alternatively as Sutton's Disease, especially in the case of major, multiple, or recurring ulcers.

The term aphtha means ulcer; it has been used for many years to describe areas of ulceration on mucous membranes. Aphthous stomatitis is a condition which is characterized by recurrent discrete areas of ulceration which are almost always painful. Recurrent aphthous stomatitis (RAS) can be distinguished from other diseases with similar-appearing oral lesions, such as certain viral exanthems or herpes simplex, by their tendency to recur, and their multiplicity and chronicity. Recurrent aphthous stomatitis is one of the most common oral conditions. At least 10% of the population suffers from it. Women are more often affected than men. About 30–40% of patients with recurrent aphthae report a family history.

Presentation

Lge aphthous ulcer on the lower lip

Aphthous ulcers are classified according to the diameter of the lesion.

Minor ulceration

"Minor aphthous ulcers" indicate that the lesion size is between 3-10 mm. The appearance of the lesion is that of an erythematous halo with yellowish or grayish color. Extreme pain is the obvious characteristic of the lesion. When the ulcer is white or grayish, the ulcer will be extremely painful and the infected lip may swell.

Major ulcerations

Major aphthous ulcers have the same appearance as minor ulcerations, but are greater than 10 mm in diameter and are extremely painful. They usually take more than a month to heal, and frequently leave a scar. These typically develop after puberty with frequent recurrences. They occur on movable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces. The lesions heal with scarring and cause severe pain and discomfort.

Herpetiform ulcerations

This is the most severe form. It occurs more frequently in females, and onset is often in adulthood. It is characterized by small, numerous, 1–3 mm lesions that form clusters. They typically heal in less than a month without scarring. Palliative treatment is almost always necessary.

Symptoms

Aphthous ulcers usually begin with a tingling or burning sensation at the site of the future aphthous ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer.

The aphthous ulcer appears as a white or yellow oval with an inflamed red border. Sometimes a white circle or halo around the lesion can be observed. The grey-, white-, or yellow-colored area within the red boundary is due to the formation of layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw, which can be mistaken for toothache; another symptom is fever. A sore on the gums may be accompanied by discomfort or pain in the teeth.

Causes

The exact cause of many aphthous ulcers is unknown but citrus fruits (e.g. oranges and strawberries), lack of sleep, illness, physical trauma, hormonal changes, menstruation, sudden weight loss, food allergies, immune system reactions and deficiencies in vitamin B12, iron, and folic acid may contribute to their development. Nicorandil and certain types of chemotherapy are also linked to aphthous ulcers.

Trauma to the mouth is the most common trigger. Physical trauma, such as that caused by toothbrush abrasions, laceration with sharp or abrasive foods (such as toast) or objects, accidental biting (particularly common with sharp canine teeth), after losing teeth, or dental braces can cause aphthous ulcers by breaking the mucous membrane. Other factors, such as chemical irritants or thermal injury, may also lead to the development of ulcers. Using a toothpaste without SLS may reduce the frequency of aphthous ulcers but some studies have found no connection between SLS in toothpaste and aphthous ulcers. Celiac disease has been suggested as a cause of aphthous ulcers; small studies of patients with Celiac disease did not demonstrate a conclusive link between the disease and aphthous ulcers but some patients benefited from eliminating gluten from their diet.

Treatment

Non-prescription treatments

Vitamin B12 (1 mg dissolved under the tongue each evening) has been found to be effective in treating recurrent aphthous ulcers, regardless of whether there is a vitamin deficiency present.

Suggestions to reduce the pain caused by an ulcer include: avoiding spicy food, rinsing with salt water or over-the-counter mouthwashes, proper oral hygiene and non-prescription local anesthetics. Active ingredients in the latter generally include benzocaine, benzydamine or choline salicylate.

Anaesthetic mouthwashes containing benzydamine hydrochloride have not been shown to reduce the number of new ulcers or significantly reduce pain, and evidence supporting the use of other topical anaesthetics is very limited though some individuals may find them effective. In general their role is limited; their duration of effectiveness is generally short and does not provide pain control throughout the day; the medications may cause complications in children.

Evidence is limited for the use of antimicrobial mouthwashes but suggests that they may reduce the painfulness and duration of ulcers and increase the number of days between ulcerations, without reducing the number of new ulcers.

Liquorice root extract may help heal or reduce the growth of aphthous ulcers if applied early on and is available in over-the-counter patches.

Dentists can also provide laser treatments with good results.

A thick paste made of crushed aspirin and water applied to the canker sore may reduce pain after the initial burning sensation caused by application subsides, and may prevent the sore from further irritation allowing it to heal more quickly.

Prescription treatments

Corticosteroid preparations containing hydrocortisone hemisuccinate or triamcinolone acetonide to control symptoms are effective in treating severe aphthous ulcers.

Multiple ulcers may be treated with an antiviral medication. The application of silver nitrate will cauterize the sore; a single treatment reduces pain but does not affect healing time. though in children it can cause tooth discoloration if the teeth are still developing. The use of tetracycline is controversial, as is treatment with levamisole, colchicine, gamma-globulin, dapsone, estrogen replacement and monoamine oxidase inhibitors.

Alternatively, a newer medication known as Debacterol, a topical sulfuric acid/phenolics solution used as a cauterizing agent has proven to be a highly effective treatment against canker sores, which has shown significantly to reduces pain and increases healing time. However, Debacterol is not yet FDA approved.

Canker sores contain lots of "activated" mast cells. Activated mast cells secrete histamines (known to cause allergy) and leukotrienes (known to cause inflammation). Aphthasol (Amlexanox 5%) is known to inhibit histamine and leukotriene secretion by mast cells. The application of Amlexanox at prodromal stage prevents/reduces ulceration in humans. Therefore Amlexanox inhibits these processes before tissue damage occurs. Aphthasol is the first and only FDA-approved prescription drug indicated for the treatment of canker sores.

OraDiscA-(amlexanox 2mg) is a mucoadhesive, water-erodible disc incorporating 2mg of Amlexanox for the treatment and prevention of aphthous ulcers. A thin, flexible, biodegradable composite film is composed of a backing layer attached to a layer which contains both the mucosal adhesive polymers and Amlexanox. While adhering to the mucosal tissue, the polymer absorbs moisture, commences disintegration while delivering the active drug Amlexanox into the lesion. Complete erosion and drug release occurs in less than 60 minutes.

Severe outbreaks are sometimes treated with a corticosteroid such as prednisone and anti-viral medications such as acyclovir. Prednisone can help, but can have some serious side effects which should also be considered.

Prevention

Oral and dental measures

Regular use of non-alcoholic mouthwash may help prevent or reduce the frequency of sores. In fact, informal studies suggest that mouthwash may help to temporarily relieve pain.
In some cases, switching toothpastes can prevent aphthous ulcers from occurring with research looking at the role of sodium dodecyl sulfate (sometimes called sodium lauryl sulfate, or with the acronymes SDS or SLS), a detergent found in most toothpastes. Using toothpaste free of this compound has been found in several studies to help reduce the amount, size and recurrence of ulcers.
Dental braces are a common physical trauma that can lead to aphthous ulcers and the dental bracket can be covered with wax to reduce abrasion of the mucosa. Avoidance of other types of physical and chemical trauma will prevent some ulcers, but since such trauma is usually accidental, this type of prevention is not usually practical.

Nutritional therapy

Zinc deficiency has been reported in people with recurrent aphthous ulcers. The few small studies looking into the role of zinc supplementation have mostly reported positive results particularly for those people with deficiency, although some research has found no therapeutic effect.

bad breath

2009-08-31T04:37:00.000-07:00

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:

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

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.
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.
BANA test: this test is directed to find the salivary levels of an enzyme indicating the presence of certain halitosis-related bacteria.
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:

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.
Eating a healthy breakfast with rough foods helps clean the very back of the tongue.
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.
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).
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).
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

2009-08-31T03:45:00.000-07:00

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

2009-08-13T00:51:00.001-07:00

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

2009-08-13T00:51:00.000-07:00


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.

Signs and symptoms

Muscles

TMJ diagram

Temporomandibular joints

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:

Trauma
Repetitive unconscious jaw movements called bruxing.
Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
Jaw thrusting (causing unusual speech and chewing habits).
Excessive gum chewing or nail biting.
Size of foods eaten.
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
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

Long-term approach

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.)

Dental implant

2009-08-13T00:46:00.000-07:00

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:

Immediate post-extraction implant placement.
Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
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:

Immediate loading procedure.
Early loading (1 week to 12 weeks).
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

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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

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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

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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

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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

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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

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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.

Pediatric Dentistry

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Pediatric dentistry is an age-defined specialty that provides dental health care for infants and children through adolescence, including those with special health care needs.

Pediatric dentists are trained to perform a wide range of dental procedures in children. Pediatric dentists have an in-depth knowledge on child psychology, which helps them to manage and provide efficient dental care to children. It is their responsibility to ensure a pleasant experience during a child's visit to the dentist. Most adults who are poor dental patients might have had a traumatic dental experience during their childhood.

Ideally the first dental visit of a child should begin at 8-12 months of age. Pediatric dentists are trained to perform infant examination and also to provide the necessary information regarding infant oral here. Most of the children who have regular dental visits from infancy remain caries free (decay free) throughout their lifetime.

Pediatric dentists provide children (also their parents) with information regarding prevention of dental caries, oral hygiene measures and other common oral problems thereby helping them achieve a smooth transition from milk teeth to an ideal set of permanent teeth.

Pediatric dentist provides the following dental procedures :

>> Amalgam and Composite Fillings for primary teeth
>> Pediatric root canal therapy
>> Minor orthodontic correction
>> Preventive care for cleft lip and palate children

>> Management of traumatic injuries in children

Orthodontics

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Orthodontics is a specialty of dentistry that is concerned with the study and treatment of malocclusions (improper bites), which may be a result of tooth irregularity, disproportionate jaw relationships, or both. The word comes from the Greek words orthos meaning straight or proper, and odons meaning tooth.

Orthodontic treatment can focus on dental displacement only, or can deal with the control and modification of facial growth. In the latter case it is better defined as "dentofacial orthopedics".

Orthodontic treatment can be carried out for purely aesthetic reasons with regards to improving the general appearance of patients' teeth. However, there are orthodontists who work on reconstructing the entire face rather than focusing exclusively on teeth. Treatment is most often prescribed for practical reasons such as providing the patient with a functionally improved bite (occlusion).

Definition

Orthodontics is formally defined by the American Association of Orthodontics as, "The area of dentistry concerned with the supervision, guidance and correction of the growing and mature dentofacial structures, including those conditions that require movement of teeth or correction of malrelationships between and among teeth and facial bones by the application of forces and/or the stimulation and redirection of the jaws within the craniofacial complex."

History

Irregular teeth have been a major problem for some individuals since antiquity and attempts to correct them go back to at least 1000 B.C. Orthodontic appliances have been found from Greek and Etruscan materials.

Edward Angle was the first orthodontist—the first dentist to limit his practice to orthodontics only. He is considered the "Father of Modern Orthodontics."

Methods

If the main goal of the treatment is the dental displacement, most commonly a fixed multibracket therapy is used. In this case orthodontic wires are inserted into dental braces, which can be made from stainless steel or a more aesthetic ceramic material.

Dental braces, with a powerchain, removed after completion of treatment.

Also removable appliances, or "plates", headgear, expansion appliances, and many other devices can be used to move teeth. Functional and orthopaedics appliances are used in growing patients (age 5 to 14) with the aim to modify the jaw dimensions and relationship if these are altered. This therapy is frequently followed by a fixed multibracket therapy to align the teeth and refine the occlusion.

Hawley retainers are the most common type of retainers. This picture shows retainers for the top and bottom of the mouth.

After a course of active orthodontic treatment, patients will often wear retainers, which will maintain the teeth in their improved position while the surrounding bone reforms around them. The retainers are generally worn full-time for braxes a short period, perhaps 6 months to a year, and then worn periodically (typically nightly during sleep) for as long as the ors. It is possible for the teeth to stay aligned without regular retainer wear. However, there are many reasons teeth will crowd as a person ages; thus there is no guarantee that teeth, orthodontically treated or otherwise, will stay aligned without retention. For this reason, many orthodontists recommend periodic retainer wear for many years (or indefinitely) after orthodontic treatment.

Appropriately trained doctors align the teeth with respect to the surrounding soft tissues, with or without movement of the underlying bones, which can be moved either through growth modification in children or jaw surgery (orthognathic surgery) in adults.

Headgear & J-hooks for connection into the patient's mouth.

Several appliances are utilized for growth modification; including functional appliances, Headgear and Facemasks.

These "orthopedic appliances" may influence the development of an adolescent's profile and give an improved aesthetic and functional result.

Conditions

The most common condition that the methods of orthodontics are used for is correcting anteroposterior discrepancies. Another common situation leading to orthodontic treatment is crowding of the teeth.

Anteroposterior discrepancies

Anteroposterior discrepancies are deviations between the teeth of the upper and lower jaw in the anteroposterior direction. For instance, the top teeth can be too far forward relative to the lower teeth ("increased overjet".) The headgear is attached to the braces via metal hooks or a facebow and is anchored from the back of the head or neck with straps or a head-cap. Elastic bands are typically then used to apply pressure to the bow or hooks. Its purpose is to slow-down or stop the upper jaw from growing, hence preventing or correcting an overjet. For more details and photographs, see Orthodontic headgear.

Orthodontic treatment of crowded teeth; the canine is being pulled down into proper position with highly flexible co-axial wire. This patient also presents with a cross bite, where the upper molar is more lingual (towards the tongue) than the opposing lower molar.

Crowding of teeth

Another common situation leading to orthodontic treatment is crowding of the teeth. In this situation, there is insufficient room for the normal complement of adult teeth, which may require tooth removal in order to make enough room for the remaining teeth.

Diagnosis and treatment planning

In diagnosis and treatment planning, the orthodontist must (1) recognize the various characteristics of malocclusion and dentofacial deformity; (2) define the nature of the problem, including the etiology if possible; and (3) design a treatment strategy based on the specific needs and desires of the individual. (4) present the treatment strategy to the patient in such a way that the patient fully understands the ramifications of his/her decision.

Training

Orthodontics was the first recognized specialty field within dentistry. Many countries have their own systems for training and registering orthodontic specialists. A two to three year period of full-time post-graduate study is required for a dentist to qualify as an orthodontist.

Europe

In the United Kingdom, this training period lasts three years, after completion of a membership from a Royal College. A further two years is then completed to train to consultant level, after which a fellowship examination from the Royal College is sat. In other parts of Europe, a similar pattern is followed. It is always worth contacting the professional body responsible for registering orthodontists to ensure that the orthodontist you wish to consult is a recognized specialist.

United States, Canada, Australia, and New Zealand

A number of dental schools and hospitals offer advanced education in the specialty of Orthodontics to dentists seeking postgraduate education. The courses range from two to three years (with the majority being 3 years) of full-time classes in the theoretical and practical aspects of orthodontics together with clinical experience. Generally, admission is based on an application process followed by an extensive interviewing process by the institution, in order to select the best candidates. Candidates usually have to contact the individual school directly for the application process.

India

In India, many dental colleges affiliated to universities offer orthodontics as specialisation in Master of Dental Surgery ( M.D.S ) programme.The minimum qualification for M.D.S is Bachelor of Dental Surgery ( B.D.S ). The present course for MDS in Orthodontics stands at 3 years in all dental colleges in India which are recognised by the Dental Council of India. The Indian Orthodontic Society was established in 1965. The Indian Society of Orthodontics for General Practitioners (ISOGP), established in 2008, represents GP's and members from other dental specialties who practices orthodontics.

Oral and maxillofacial surgery

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Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is a recognized international surgical specialty.

Regulations

In the U.S.A., Canada, Australia, and New Zealand, oral and maxillofacial surgery is one of the 9 specialties recognized by the American Dental Association, Royal College of Dentists of Canada, and Royal Australasian College of Dental Surgeons, training programs lead to the trainee obtaining qualifications in both Medicine and Dentistry.

In other parts of the world oral and maxillofacial surgery as a specialty exists but under different forms as the work is sometimes performed by a single or dual qualified specialist depending on each country's regulations and training opportunities available.

Oral and maxillofacial surgeons

An oral and maxillofacial surgeon is a regional specialist surgeon treating the entire craniomaxillofacial complex: anatomical area of the mouth, jaws, face, skull, as well as associated structures.

Maxillofacial surgeons are usually initially qualified in dentistry and have undergone further surgical training. Some OMS residencies integrate a medical education as well & an appropriate degree in medicine (MBBS or MD or equivalent) is earned, although in the United States there is legally no difference in what a dual degree OMFS can do compared to someone who earned a four year certificate. Oral & maxillofacial surgery is universally recognized as a one of the nine specialties of dentistry. However also in the UK and many other countries OMFS is a medical specialty as well culminating in the FRCS (Fellowship of the Royal College of Surgeons). Regardless, all oral & maxillofacial surgeons must obtain a degree in dentistry (BDS, BDent, DDS, or DMD or equivalent) before being allowed to begin residency training in oral and maxillofacial surgery.

They also may choose to undergo further training in a 1 or 2 year subspecialty fellowship training in the following areas:

Head and neck cancer - microvascular reconstruction
Cosmetic facial surgery
Craniofacial surgery/Pediatric Maxillofacial surgery
Cranio-maxillofacial trauma

The popularity of oral and maxillofacial surgery as a career for persons whose first degree was medicine, not dentistry, seems to be increasing. Integrated programs are becoming more available to medical graduates allowing them to complete the dental degree requirement in about 3 years in order for them to advance to subsequently complete Oral and Maxillofacial surgical training.

Surgical procedures

Treatments may be performed on the craniomaxillofacial complex: mouth, jaws, neck, face, skull, and include:

Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth extractions, extractions on medically compromised patients, bone grafting or preprosthetic surgery to provide better anatomy for the placement of implants, dentures, or other dental prostheses)
Diagnosis and treatment of benign pathology (cysts, tumors etc.)
Diagnosis and treatment (ablative and reconstructive surgery, microsurgery) of malignant pathology (oral & head and neck cancer).
Diagnosis and treatment of cutaneous malignancy (skin cancer), lip reconstruction
Diagnosis and treatment of congenital craniofacial malformations such as cleft lip and palate and cranial vault malformations such as craniosynostosis, (craniofacial surgery)
Diagnosis and treatment of chronic facial pain disorders
Diagnosis and treatment of temporomandibular joint (TMJ) disorders
Diagnosis and treatment of dysgnathia (incorrect bite), and orthognathic (literally "straight bite") reconstructive surgery, orthognathic surgery, maxillomandibular advancement, surgical correction of facial asymmetry.
Diagnosis and treatment of soft and hard tissue trauma of the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures.
Splint and surgical treatment of sleep apnea, maxillomandibular advancement, genioplasty (in conjunction with sleep labs or physicians)
Surgery to insert osseointegrated (bone fused) dental implants and Maxillofacial implants for attaching craniofacial prostheses and bone anchored hearing aids.
Cosmetic surgery limited to the head and neck: (rhytidectomy/facelift, browlift, blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplasty, oculoplastics, neck liposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel etc.)

Australia, Canada, New Zealand and the United States

Oral and Maxillofacial Surgery is one of the 9 dental specialties recognized by the American Dental Association, Royal College of Dentists of Canada, and the Royal Australasian College of Dental Surgeons. Oral and Maxillofacial Surgery requires 4–6 years of further formal University training after dental school (DDS, BDent, DMD or BDS). Four-year residency programs grant a certificate of specialty training in Oral and Maxillofacial Surgery. Six-year residency programs grant the specialty certificate in addition to a medical degree (MD, MBBS, MBChB etc.). Specialists in this field are designated registrable U.S. “Board Eligible” and warrant exclusive titles. Approximately 50% of the training programs in the U.S., 100% of the programs in Australia and New Zealand, and 20% of Canadian training programs, are dual-degree leading to dual certification in Oral and Maxillofacial Surgery and Medicine (MD, MBBS, MBChB etc).

The typical training program for an Oral and Maxillofacial Surgeon is:

4 Years Undergraduate Study (BA, BSc, or equivalent)
4 Years Dental Study (DMD, BDent, DDS or BDS)
4 - 6 Years Residency Training (additional time for acquiring medical degree)
After completion of surgical training most undertake final specialty examinations: (U.S. "Board Certified (ABOMS)"), (Australia/NZ: "FRACDS(OMS)"), or (Canada: "FRCD(C)(OMS)").
Many dually qualified oral and maxillofacial surgeons are now also obtaining Fellowships with the American College of Surgeons (FACS)
Average total length after Secondary School: 12 - 14 Years

In addition, graduates of Oral and Maxillofacial Surgery training programs can pursue fellowships, typically 1 – 2 years in length, in the following areas:

Head and neck cancer - microvascular reconstruction
Cosmetic facial surgery (facelift, rhinoplasty, etc.)
Craniofacial surgery/Pediatric Maxillofacial surgery (cleft lip and palate repair, surgery for craniosynostosis, etc.)
Cranio-maxillofacial trauma (soft tissue and skeletal injuries to the face, head and neck)

Notable oral and maxillofacial surgeons

Luc Chikhani reconstructed Trevor Rees-Jones's face, which was literally flattened by the impact of the car crash that killed Diana, Princess of Wales.
Bernard Devauchelle a French oral and maxillofacial surgeon at Amiens University Hospital who in November 2005 successfully completed the first face transplant on Isabelle Dinoire.

Organizations

Asosiacion Colombiana de Cirugia Oral y Maxilofacial- ACCOMF
Association of Oral and Maxillofacial Surgeons of India
American Association of Oral and Maxillofacial Surgeons
American Board of Oral and Maxillofacial Surgery
American College of Surgeons
Australian and New Zealand Association of Oral and Maxillofacial Surgeons
The Royal College of Surgeons of England
Association canadienne des spécialistes en chirugie buccale et maxillo-faciale
Faculty of Dental Surgery of The Royal College of Surgeons of England
Directive 2001/19/EC (Official Journal of the European Communities L 206, 31.07.2001)
Indonesia Association Of Oral and Maxillofacial Surgeon
European Association for Cranio-Maxillofacial Surgery
Internacional Association of Oral and Maxillofacial Surgeons
British Association of Oral and Maxillofacial Surgeons

Oral and maxillofacial radiology

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Orthopantomogram

Oral and maxillofacial radiology is a specialty of Dentistry; that is mainly concerned with performing ,understanding and interpretation of diagnostic imaging modalities used in dentistry and other health care professions related to facial, neck and oral structures.

Dental/Maxillo-facial imaging techniques including Ultrasound scan, cone beam CT, MRI, Orthopantomogram, intra-oral imaging (e.g. bitewing, peri-apical and occlusal radiographs) in addition to special tests like sialographs.

Stomatognathic disease

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Stomatognathic disease refers to the diseases of the mouth ("stoma") and [[jaw]] ("gnath"). The etymology is similar to that of the term Gnathostomata. It is the term used by MeSH (along with the synonym dental diseases), but other organizations use different terms.

The American Dental Association uses the term "oral and maxillofacial pathology", and describes it as "the specialty of dentistry and pathology which deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes and effects of these diseases."

The World Health Organization uses the term "Diseases of oral cavity, salivary glands and jaws."

Endodontics

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If decay progresses to the first stage, a small filling will be required. If decay develops to the third stage depicted, root canal therapy will be required.

Endodontics, from the Greek endo (inside) and odons (tooth), is one of the nine specialties of dentistry recognized by the American Dental Association, and deals with the tooth pulp and the tissues surrounding the root of a tooth. If the pulp (containing nerves, arterioles and venules as well as lymphatic tissue and fibrous tissue) has become diseased or injured, endodontic treatment is required to save the tooth.

Lentulo spiral

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A lentulo spiral. The notches at left allow it to fit into a slow-speed latch handpiece.

A Lentulo spiral is a dental instrument used to properly distribute root canal sealer and cement evenly throughout the root canal system, as when performing endodontic therapy or a post and core cementation.

Maillefer’s Lentulo spiral, produced by Dentsply, is the only one licensed to use the Lentulo name; however, the term is generally used to refer to any of the various brands of root canal sealer and cement distributing spirals.

Elastic Ligature (orthodontic)

2009-08-07T00:48:00.002-07:00

Elastic ligature is a term used in orthodontics for the small elastic that is used to affix the archwire to the bracket. Ligatures are usually changed at each adjustment, and come in many varied colors including transparent. A series of ligatures connected to each other and used to pull teeth together with more strength is called a powerchain. Ligatures can also be made of wire.

Applying powerchain ligatures

Self Ligation is an orthodontic term used to describe a bracket with a sliding or rotating mechanism to ligate an archwire. This type of bracket replaces elastic ligatures that are traditionally used. Self ligation typically cuts orthodontic appointment time drastically. Currently, self ligating brackets make up about 10 percent of total bracket sales worldwide

Osteotome

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Osteotomes used in dental implantation

Bernhard Heine's osteotome

Component parts of the osteotome, and the instrument in use

An osteotome is an instrument used for cutting or preparing bone.

The instrument was invented by Bernhard Heine, a German physician in Würzburg, in 1830. Heine's invention was used as a bone saw, especially for opening the skull. It was a kind of chain saw moved by turning a winder. Heine's osteotome is no longer used in surgery.

Today osteotomes are used in dental implantation. With the osteotome technique, osteoplastic procedures have been developed in which the bone quality (compaction of local bone) and bone quantity (ridge extension in horizontal and vertical dimension) are routinely improved and adequate primary stability of the implants can be ensured with a high degree of predictability.

Periodontal curette

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Gracey curettes have sharp edges on only one side of their blades. There are two site-specific Gracey curettes -- posterior mesial (white ring) and posterior distal (blue ring), in addition to the anterior curette (red ring).

Universal curettes have sharp edges on both side of their blades. Therefore, only two instruments are necessary -- anterior (pink ring) and posterior (purple ring).

A periodontal curette is a dental instrument used primarily in the prophylactic and periodontal care of human teeth. The working tips are fashioned in a variety of shapes and sizes, but they are always rounded at the tip in order to make subgingival cleansing less traumatic to the gingiva. Periodontal scalers feature a sharp tip to access supragingival calculus in tight embrasure spaces, thus making the curette the choice instrument for treating subgingival areas of calculus accumulation.

Curettes are best used when the terminal shank, namely, the last portion of the handle attached to the blade, is held parallel to the long axis of the tooth. To facilitate proper usage, instruments often come with posterior analogs which possess angled terminal shanks.

While the blade of the universal curette is situated perpendicular to the edge of the terminal shank, the blade of the Gracey curette is only offset by 70 degrees, giving the blade a lower cutting edge and an upper non-cutting edge.

Classically, there are two recognized groups of curettes.

A universal curette has a blade that is perpendicular to its terminal shank. This orientation allows the blade to be used against either the mesial or distal surface of a tooth. Because this type of periodontal curette was developed at the Columbia University College of Dental Medicine, it is also known as a Columbia curette.
The Gracey curette, invented by Dr Clayton Gracey with the help of Hugo Friedman of Hu-Friedy Manufacturing company in the early 1940's, has a blade that is laterally offset by 70 degrees relative to the shank. Consequently, a Gracey curette has a lower cutting edge and an upper non-cutting edge. Because only one side of each blade can cut, Gracey curettes are site-specific, and a posterior instrument used to clean mesial surfaces of teeth won't work on distal surfaces , and vice versa. "Gracey" Christina Patrick blades used for mesial surfaces of anterior teeth from the facial are only suitable for the distal surfaces of the same teeth when access is performed from the lingual.Gracey Curettes 1/2 ,3/4 ,5/6 are used on the anterior sextants of teeth.7/8 and 9/10 are used on the buccal and lingual portions of posterior teeth.11/12 and 15/16 are used on the mesial portions of posterior teeth.13/14 and 17/18 are used on the distal portions of posterior teeth.

Dental syringe

2009-08-07T00:46:00.000-07:00

A dental syringe is a syringe used by dentists for the injection of an anesthetic. It consists of a breech-loading syringe fitted with a sealed cartridge containing anesthetic solution.

The ancillary tool (generally part of a dental engine) used to supply either water or air to the oral cavity for the purpose of cleaning debris away from the area the dentist is working on, is also referred to as a dental syringe. A 3-way syringe has separate internal channels supplying air, water or a mist of air and water, created by combining the pressurized air with the waterflow. The syringe tip can be separated from the main body and replaced when necessary.

Dental anesthesia

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Forms of dental anesthesia are similar to general medical anesthesia except for the use of nitrous oxide, relatively uncommon outside of the dental field in the U.S.

Local anesthetics

The most commonly used local anesthetic is lidocaine (also called xylocaine), a modern replacement for novocaine and procaine. Its half-life in the body is about 1.5-2 hours. Other local anaesthetics in current use include septocaine, marcaine (a long-acting anesthetic), and mepivacaine. A combination of these may be used depending on the situation. Also, most agents come in two forms: with and without epinephrine.

The most common technique, effective for the lower teeth and jaw, is inferior alveolar nerve anaesthesia. An injection blocks sensation in the inferior alveolar nerve, which runs from the hinge of the jaw down the back of the mandible, connecting to the lower teeth, lower lip, chin, and tongue. The inferior alveolar nerve probably is anesthetized more often than any other nerve in the body. To anesthetize this nerve, the dentist inserts the needle somewhat posterior to the patient’s last molar. Several nondental nerves are usually anesthetized during an inferior alveolar block. The mental nerve, which supplies cutaneous innervation to the anterior lip and chin, is a distal branch of the inferior alveolar nerve. When the inferior alveolar nerve is blocked, the mental nerve is blocked also, resulting in a numb lip and chin. Nerves lying near the point where the inferior alveolar nerve enters the mandible often are also anesthetized during inferior alveolar anesthesia. For example, the lingual nerve can be anesthetized to produce a numb tongue. The facial nerve lies some distance from the inferior alveolar nerve, but in rare cases anesthetic can diffuse far enough posteriorly to anesthetize that nerve. The result is a temporary facial palsy (paralysis or paresis), with the injected side of the face drooping because of flaccid muscles, which disappears when the anesthesia wears off. If the facial nerve is cut by an improperly inserted needle, permanent facial palsy may occur.

The superior alveolar nerves are not usually anesthetized directly because they are difficult to approach with a needle. For this reason, the upper are usually anesthetized locally by inserting the needle beneath the oral mucosa surrounding the teeth.

Other anaesthetics

Nitrous oxide (N2O), also known as "laughing gas", binds to the hemoglobin in the lungs, where it travels to the brain, leaving a dissociated and euphoric feeling for most patients. N2O is typically used in conjunction with Procaine. Nitrous oxide is used in combination with Oxygen. Often (especially with children) a sweet smelling fruity scent similar to an auto scent is used with the gas to inspire deep inhalation. Nitrous oxide nose respirators are available to dentists pre-scented with a fruity smell and used by some dentists especially on children.
Eugenol — made from clove oil, this is a topical anesthetic also used in the common dental material ZOE (zinc oxide eugenol).
Topical anastethics — benzocaine, eugenol, and forms of xylocaine are used topically to numb various areas before injections or other minor procedures
General anesthesia — drugs such as versed, ketamine, propofol and fentanyl are used to put the patient in a twilight sleep or render them completely unconscious and unaware of pain.
Versed a drug that represses memories of the procedure is usually given two hours prior to the procedure in combination with Tylenol in General anesthesia so the patient will go home with no memories of being in surgery.
Sevoflurane gas in combination with Nitrous oxide and Oxygen is often used during General anesthesia followed by the use of isoflurane gas to maintain anesthesia during the procedure. In children sweet fruity scents are often used with the gases to inspire deep inhalation. Scents come in cherry, apple, bubblegum, watermelon, etc...
Propofol a drug with similar effects to Sodium Pentathol is often used through intravenous infusion through an IV during General anesthesia after gasses are initiated.
Morphine is often used to control pain during the dental surgery under General anesthesia. The morphine is usually administered through IV.
Ketorolac is often administered through IV to suppress both pain and inflammation while under General anesthesia. *Ketorolac is often administered through IV to suppress both pain and inflammation while under General anesthesia.

Other Drugs Often used During General Anesthesia

Decadron a steroid is often administered through IV to suppress inflammation and swelling resulting during the surgery while under General anesthesia.
Ondansetron brand named Zofran is often administered to prevent nausea during the surgery which may result from the blood draining into the stomach while under General anesthesia. Or it is given to the patient after the procedure for postoperative nausea which may result from the anesthesia itself which was administered.

Blocks

Electrical nerve blocks — a technology that involves using electrical current to block the reception or generation of pain signals.
Branch block — a common form of local dental anesthesia, blocks the reception of pain for one quadrant of the mouth at a time. Typically given in the buccal surface (cheek). (IAB, MNB are types of this block)
Dental block — given below the tooth in question. Used usually for minor procedures such as fillings.
Palatal block— given into the hard palate, useful in numbing the upper teeth.
Intraosseous — an injection of local anesthetic given directly into the osseous (bone) structure of the tooth.
Intrapulpal — an injection of local anesthetic given directly into the pulp of the tooth to completely desensitize the tooth.
An alternative to chemical or electrical blocks, acupuncture or acupressure is rarely used.

Dental syringe

A dental syringe is a syringe used by dentists for the injection of an anesthetic. It consists of a breech-loading syringe fitted with a sealed cartridge containing anesthetic solution.

General anesthesia

Dentists who have completed a training program in anesthesiology may also administer general IV and inhalation anesthesthetic agents.

Mouth prop

2009-08-07T00:44:00.001-07:00

A mouth prop (also "Bite block") is a wedge-shaped implement used in dentistry for dentists working with children and other patients who have difficulty keeping their mouths open wide and steady during a procedure, or during procedures where the patient is sedated. It has a rubber like texture and is typically made from Thermoplastic Vulcanizate (TPV) material. They come in several different sizes, from pediatric to adult, and are typically ridged as to use the back teeth to hold them in place.

Periodontal probe

2009-08-07T00:43:00.002-07:00

A periodontal probe is an instrument in dentistry commonly used in the dental armamentarium. It is usually long, thin, and blunted at the end. The primary purpose of a periodontal probe is to measure pocket depths around a tooth in order to establish the state of health of the periodontium. There are markings inscribed onto the head of the instrument for accuracy and readability.

Michigan O probe with Williams markings (left) and Naber's probe with shades alternating every 3 mm (right).

Proper use of the periodontal probe is necessary to maintain accuracy. The tip of the instrument is placed with light pressure of 10-20 grams into the gingival sulcus, which is an area of potential space between a tooth and the surrounding tissue. It is important to keep the periodontal probe parallel to the contours of the root of the tooth and to insert the probe down to the base of the pocket. This results in obscuring a section of the periodontal probe's tip. The first marking visible above the pocket indicates the measurement of the pocket depth. It has been found that the average, healthy pocket depth is around 3 mm with no bleeding upon probing. Depths greater than 3 mm can be associated with "attachment loss" of the tooth to the surrounding alveolar bone, which is a characteristic found in periodontitis. Pocket depths greater than 3 mm can also be a sign of gingival hyperplasia.

There are many different types of periodontal probes, and each has its own manner of indicating measurements on the tip of the instrument. For example, the Michigan O probe has markings at 3 mm, 6 mm and 8 mm and the Williams probe has circumferential lines at 1 mm, 2 mm, 3 mm, 5 mm, 7 mm, 8 mm, 9 mm, and 10 mm . The PCP12 probe with Marquis markings has alternating shades every 3 mm. Unlike the previous two mentioned, the Naber's probe is curved and is used for measuring into the furcation area between the roots of a tooth.

PCP12 probe with shades alternating every 3 mm. The probe is on a modified Novatech shank, intended to make it easier to align the probe with the vertical axis of the teeth.

The periodontal probe can also be used to measure other dental instruments, tooth preparations during restorative procedures, gingival recession, attached gingiva, and oral lesions or pathologies.

^ Wilkins, 1999
^ Wilkins, 1999
^ Wilkins, 1999

Explorer (dental)

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A No. 23 explorer, also known as a 'sickle probe'

A dental explorer (sickle probe) is an instrument in dentistry commonly used in the dental armamentarium. A sharp point at the end of the explorer is used to enhance tactile sensation.

Until recently, it was advised that dentists use the explorer to determine the presence of tooth decay on tooth enamel. Some dental professionals have questioned this practice. Since enamel is demineralized in the early stages of tooth decay,the use of an explorer opens a cavity in the enamel where none existed previously. Instead, they argue that fluoride and oral hygiene should be used to remineralize the enamel and prevent it from decaying further. This debate still continues because sometimes decay can be difficult to diagnose without tactile verification. Additionally, radiographs and products designed to identify decay help the dental professional make a final diagnosis of tooth decay.

There are various types of explorers, though the most common one is the No. 23 explorer, which is also known as a "shepherd's hook". Other types include the 3CH (also known as "cowhorn" or "pigtail") and No. 17 explorers, which are useful for the interproximal areas between teeth.

Mouth mirror

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A mouth mirror

A mouth mirror or dentist's mirror is an instrument used in dentistry. The head of the mirror is usually round, and the most common sizes used are the No. 4 and No. 5. A No. 2 is sometimes used when a smaller mirror is needed, such as when working on back teeth with a dental dam in place. The mouth mirror has a wide range of uses. Three of its most important functions are allowing indirect vision by the dentist, reflecting light onto desired surfaces, and retraction of soft tissues.

Indirect vision is needed in certain locations of the mouth where visibility is difficult or impossible. The posterior (or lingual) surfaces of the anterior maxillary teeth is a notable area where mouth mirrors are often used. Other areas of the mouth can be viewed more readily with the mouth mirror, even though it would be possible to see them if the dentist or dental hygienist adjusted their body into a poor position. Without the mouth mirror, poor body positioning would occur daily and lead to chronic postural problems, especially of the back and neck.

There are other areas of the mouth where lighting is difficult, even with overhead dentists' lights. In these instances, the mouth mirror is used to reflect light onto those surfaces. This is especially useful if the mirror is simultaneously being used for indirect vision of an obscure area.

Additionally, the mouth mirror is used to retract tissues, such as the tongue or cheeks, to gain better visualization of the teeth.

Dentist's mirrors are also commonly used by engineers to allow vision in tight spaces and around corners in equipment. They are a common tool in optics and laser labs as well.

Dental instruments

2009-08-07T00:39:00.000-07:00

Mouth mirror, a commonly used dental instrument

Dental instruments are the tools that dental professionals use to provide dental treatment. They include tools to examine, manipulate, restore and remove teeth and surrounding oral structures.

Standard instruments

Standard instruments are the instruments used to examine, restore and extract teeth and manipulate tissues.

Examination instruments

These tools allow the dental professional to manipulate tissues, to allow better visual access during treatment or during dental examination.

Mirror

Dental mirrors are used by the dentist or dental auxiliary to view a mirror image of the teeth in locations of the mouth where visibility is difficult or impossible. They also are useful for reflecting light onto desired surfaces, and with retraction of soft tissues to improve access or vision.

Probes

Sickle probe (dental explorer),
Periodontal probe, straight probe

Retractors

Mouth prop, dental mirror, cheek retractor, tongue retractor, lip retractor.

Local anesthesia

Dental anesthesia and Dental syringe.

Dental drills

A high-speed dental handpiece.

High speed air driven, slow speed, friction grip, surgical hand piece. Straight handpiece with a sharp bur.

Burs

Dental Burs cutting surface are either made of a multifluted tungsten carbide, a diamond coated tip or a stainless steel multi fluted rosehead. There are many different types and classifications of burs some of the most common are: the round bur (sizes ¼ to 10) or inverted cone (sizes 33½ to 90L) Burs are also classified by the type of shank. For instance a latch type, or right angle bur is only used in the slow speed handpiece with contra-angle attachment. Long shank or shaft is only used in the slow speed when the contra-angle is not in use, and finally a friction grip bur which is a small bur used only in the high-speed handpiece.

There are many bur shapes that are utilized in various specific procedures.

Operative burs

Flat fissure, pear-shaped, football, round, tapered, flame, chamfer, bevel, bud bur, steel, inverted cone, diamond, brown stone, greenstone

Restorative instruments

Excavators

spoon excavator: which is used to remove soft carious decay
half hollenbach: this instrument is usually used to test for overhangs or flash
Chisels:

Straight - bevels the cavosurface margin and used in 3, 4 and 5 classifications of cavities on the maxillary. Wedelstaedt - only used in the anterior for classes 3, 4 and 5 as well. Bin Angle - this is held in a pen grasp and used for class 2 maxillary only.

Burnishers

flat plastic, ball burnisher, beavertail burnisher, cone burnisher, J Burnisher, pear shaped burnisher

Pluggers

Amalgam plugger, 49 plugger

Periodontal scalers

Curettes

Universal curettes, Gracey curettes resr

Ultrasonic scalers

Prosthodontic instruments

Removable prosthodontics

Spatula, Fox plane, Willis Gauge, Bunsen burner, wax knife, Le cron, calipers

Extraction/surgical instruments

Dental forceps

Upper Universals, Upper Universal Fine, Lower universals, Upper Canine, Upper straight long, Upper straight short, Upper right molar, Upper left molar, Upper wisdom tooth, Greyhound, Root, Bayonet

Elevators

Narrow and wide straight and curved luxators, Couplands, Warrick James, Cryer, periosteal elevator, root-tip pick, potts, Cogswell-A.

Chisels

Osteotome

Orthodontic instruments

Ligature

distal end cutters,weingarts

Endodontic instruments

K-file, hedstrom file, gates glidden, finger spreader, Lentulo spiral, straight probe, apex locator, microscope, plugger WHT .

Toothpaste

2009-08-07T00:18:00.000-07:00

Toothpaste from a tube being applied to a toothbrush

Toothpaste is a paste or gel dentifrice used with a toothbrush to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it can aid in the removal of dental plaque and food from the teeth, aid in the elimination and/or masking of halitosis and deliver active ingredients such as fluoride or xylitol to prevent tooth and gum disease (gingivitis). Some dentist recommendations include brushing your teeth at least 2 times a day, if not more. In most or all developed countries, usage after each meal is encouraged by dentists. However when cleaning teeth with a toothbrush with toothpaste, the essential cleaning is done by the mechanical brushing, and not by the active toothpaste chemicals. Most toothpaste contains trace amounts of chemicals which are toxic when ingested, and is not intended to be swallowed.

History

Early toothpastes

The earliest known reference to toothpaste is in a manuscript from Egypt in the 4th century A.D., which prescribes a mixture of iris flowers. However, toothpastes or powders did not come into general use until the 19th century. The Greeks, and then the Romans, improved the recipes for toothpaste by adding abrasives such as crushed bones and oyster shells. In the 9th century, the Persian musician and fashion designer Ziryab is known to have invented a type of toothpaste, which he popularized throughout Islamic Spain. The exact ingredients of this toothpaste are currently unknown, but it was reported to have been both "functional and pleasant to taste". It is not known whether these early toothpastes were used alone, were to be rubbed onto the teeth with rags, or were to be used with early toothbrushes such as neem tree twigs or miswak. It is known that these twigs were used by Indians from ancient times. Neem tree twigs are said to have good medicinal effects.

Tooth powder

Tooth powders for use with toothbrushes came into general use in the 19th century in Britain. Most were homemade, with chalk, pulverized brick, or salt as ingredients. An 1866 Home Encyclopedia recommended pulverized charcoal, and cautioned that many patented tooth powders that were commercially marketed did more harm than good. Recently, homemade tooth powders are made by mixing 3 parts baking soda (cleanser) thoroughly with 1 part salt (the abrasive).

A homemade version of toothpaste can be made by mixing 3 parts baking soda and 1 part salt with: 3 teaspoons of glycerin, 10-20 drops of flavoring and 1 drop of food coloring.

Modern toothpaste

Modern toothpaste gel

Toothpaste applied to a toothbrush.

An 18th century American and British toothpaste recipe containing burnt bread has been found. Another formula around this time called for dragon's blood (a resin), cinnamon, and burnt alum.

By 1900, a paste made of hydrogen peroxide and baking soda was recommended for use with toothbrushes. Pre-mixed toothpastes were first marketed in the 19th century, but did not surpass the popularity of tooth-powder until World War I. In 1892, Dr. Washington Sheffield of New London, Connecticut, manufactured toothpaste into a collapsible tube. Sheffield's toothpaste was called Dr. Sheffield's Creme Dentifrice. He had the idea after his son traveled to Paris and saw painters using paint from tubes. In New York City in 1896, Colgate & Company Dental Cream was packaged in collapsible tubes imitating Sheffield.

Fluoride was first added to toothpastes in 1914, and was criticized by the American Dental Association (ADA) in 1937. Fluoride toothpastes developed in the 1950s received the ADA's approval. To develop the first ADA-approved fluoride toothpaste, Procter & Gamble started a research program in the early 1940s. In 1950, Procter & Gamble developed a joint research project team headed by Dr. Joseph Muhler at Indiana University to study new toothpaste with fluoride. In 1955, Procter & Gamble's Crest launched its first clinically proven fluoride toothpaste. On August 1, 1960, the ADA reported that "Crest has been shown to be an effective anticavity (decay preventative) dentifrice that can be of significant value when used in a conscientiously applied program of oral hygiene and regular professional care." Countries limit and suggest different amounts of fluoride acceptable for health. Much of Africa has a slightly higher percentage than the U.S.

In June, 2007, the US Food and Drug Administration and similar agencies in Panama, Puerto Rico and Australia advised consumers to avoid certain brands of toothpaste manufactured in China, after some were found to contain the poisonous diethylene glycol, also called diglycol or labeled as "DEG" on the tube. The chemical is used in antifreeze as a solvent and is potentially fatal.

Toothpaste is most commonly sold in flexible tubes, though containers are available. The hard containers stand straight up, availing more of the toothpaste and saving shelf space.

Ingredients and flavors

Active ingredients

Fluoride in various forms is the most popular active ingredient in toothpaste to prevent cavities. Although it occurs in small amounts in plants, animals, and some natural water sources, and has effects on the formation of dental enamel and bones, it is not considered to be a dietary essential and no deficiency signs are known. Sodium fluoride (NaF) is the most common form; some brands use sodium monofluorophosphate (Na2PO3F) or organic amine fluoride (AmF) olaflur. Much of the toothpaste sold in the United States has 1000 to 1100 parts per million fluoride ion from one of these active ingredients, in the UK the fluoride content is often higher, a NaF of 0.32% w/w (1,450 ppm fluoride) is not uncommon. This consistency leads some to conclude that cheap toothpaste is just as good as expensive toothpaste. When the magazine Consumer Reports rated toothpastes in 1998, 30 of the 38 were judged excellent. Application of fluoride also prevents moisture build-up in some surfaces. Other ingredients are less commonly used, including Hydroxyapatite nanocrystals and calcium phosphate for remineralization, and strontium chloride or potassium nitrate to reduce sensitivity.

Other ingredients

In addition to fluoride, the other fundamental ingredient in most toothpastes is an abrasive Studies have shown that abrasives in toothpaste reduce the time needed to remove plaque from the teeth by approximately 50%. Abrasives, like the dental polishing agents used in dentist's offices, also cause a small amount of enamel erosion which is termed "polishing" action. Some brands contain powdered white mica which acts as a mild abrasive, and also adds a cosmetically-pleasing glittery shimmer to the paste. Many may contain frustules of dead diatoms as a mild abrasive. The removal of plaque and calculus prevents caries and periodontal disease. The polishing of teeth removes stains from tooth surfaces, but has not been shown to improve dental health over and above the effects of the removal of plaque and calculus.

Many, though not all, toothpastes contain sodium lauryl sulfate (SLS) or another of the sulfate family. SLS is found in other personal care products as well, such as shampoo, and is largely a foaming agent although it also acts as a powerful antimicrobial. Due to the anionic charge of SLS, mouthwashes containing cetylpyridinium chloride (which has a cationic charge and thus neutralises SLS) should not be used straight after brushing. SLS may cause a greater frequency of mouth ulcers in some people as it can dry out the protective layer of oral tissues causing the underlying tissues to become damaged.

Ingredients such as baking soda, enzymes, vitamins, herbs, calcium, calcium sodium phosphosilicate, mouthwash, and/or hydrogen peroxide are often combined into base mixes and marketed as being beneficial. Some manufacturers add antibacterial agents, for example triclosan or zinc chloride, to prevent gingivitis. Triclosan is a common ingredient in the UK. Bases such as sodium hydroxide are also used to neutralize acids.

Toothpaste comes in a variety of colorings, and flavors. The more usual flavorings are some variation on mint (spearmint, peppermint, regular mint, etc). Other more exotic flavors include: anise, apricot, bubblegum, cinnamon, fennel, lavender, neem, ginger, vanilla, lemon, orange, pine. More unusual are flavors include peanut butter, iced tea, and even whisky. Unflavored toothpaste does exist, however, most are flavored and sweetened. Because sugar promotes growth of bacteria that cause tooth decay, artificial sweeteners such as sorbitol or saccharin are generally used instead. The inclusion of sweet-tasting but toxic diethylene glycol in Chinese-made toothpaste led to a multi-nation and multi-brand toothpaste recall in 2007.

Critics

Toxicity

With the exception of toothpaste intended to be used on pets such as dogs and cats, and toothpaste used by astronauts, most toothpaste is not intended to be swallowed, and doing so may cause nausea or diarrhea; fluoride toothpaste can be toxic if swallowed in large amounts. If a large amount of toothpaste is swallowed, Poison Control should be contacted immediately. Extended consumption while the teeth are forming can result in fluorosis. This is why young children should not use fluoride toothpaste except under close supervision. There are several non-fluoride toothpaste options available in the market for those who choose not to use fluoride. Natural toothpaste can contain peppermint oil, myrrh, plant extract(strawberry extract), special oils and cleansing agents. Case reports of plasma cell gingivitis have been reported with the use of herbal toothpaste containing cinnamon (Cinnamomun zeylanicum).

Environmental and health concerns

Several of the ingredients in toothpastes are found by some environmentally damaging or hazardous to the personal health. These ingredients include:

Fluoride
Artificial flavoring
Artificial colors
Triclosan
Sodium bicarbonate (baking soda)
Detergents
Binding agents
Humectants
Preservatives such as Methylparaben and Ethylparaben-parabens
Pyrophosphate
Potassium nitrate
Lauryl sarcosinate
Polyethylene glycol
Polypropylene glycol
Sodium saccharin/aspartame

Fluoride is, while required in toothpastes endorsed by the American Dental Association, does pose some health issues, namely enamel fluorosis, which can affect children at age eight and younger. Enamel fluorosis is an excess mineral deposit of fluoride on developing enamel. Triclosan is found a registered pesticide, is used as an antibacterial and antifungal agent and can destroy fragile aquatic ecosystems. The preservatives family of Methylparaben and Ethylparaben-parabens (which includes methyl-, ethyl-, propyl- and butyl-parabens) can affect the endocrine system which produces the body’s hormones. Potassium nitrate is also an aquatic environmental nasty, parabens can disrupt the hormones in animals. Lauryl sarcosinate foaming and cleansing agents are found in most soaps, shampoos and toothpastes. Serious allegations of SLS’s adverse health affects abound, though reputable sources such as the American Cancer Society have challenged the accusations Sodium saccharin/aspartame sweeteners such as sodium saccharin are added for taste. Other flavors are usually strong essential oils in the mint family.

As a direct result of these concerns, some people have started making their own tooth paste instead, which -while still not completely ecologic due to the use of baking soda- still eliminates much environmentally or health damaging ingredients. Also, commercial toothpastes are made which are less or even non-environmentally damaging. Such preparations are eg made from herbal resins, propolis and myrrh.

Striped toothpaste

The red area represents the material used for stripes, and the rest is the main toothpaste material. The two materials are not in separate compartments; they are sufficiently viscous that they will not mix. Applying pressure to the tube causes the main material to issue out through the pipe. Simultaneously, some of the pressure is forwarded to the stripe-material, which is then pressed onto the main material through holes in the pipe.

Striped toothpaste was invented by a New Yorker named Leonard Lawrence Marraffino in 1955. The patent (US patent 2,789,731, issued 1957) was subsequently sold to Unilever, who marketed the novelty under the 'Stripe' brand-name in the early 1960s. This was followed by the introduction of the 'Signal' brand in Europe in 1965 (UK patent 813,514). Although 'Stripe' was initially very successful, it never again achieved the 8% market share that it cornered during its second year.

Marraffino's design, which remains in use for single-color stripes, is simple. The main material, usually white, sits at the crimp end of the toothpaste tube and makes up most of its bulk. A thin pipe, through which that carrier material will flow, descends from the nozzle to it. The stripe-material (this was red in 'Stripe') fills the gap between the carrier material and the top of the tube. The two materials are not in separate compartments. The two materials are sufficiently viscous that they will not by-chance mix with the other material. When pressure is applied to the toothpaste tube, the main material squeezes down the thin pipe to the nozzle. Simultaneously, the pressure applied to the main material causes pressure to be forwarded to the stripe material, which then issues out through small holes (in the side of the pipe) onto the main carrier material as it is passing those holes.

In 1990 Colgate-Palmolive was granted a patent (USPTO 4,969,767) for two differently-colored stripes. In this scheme, the inner pipe has a cone-shaped plastic guard around it, and about half way up its length. Between the guard and the nozzle-end of the tube is then a space for the material for one color, which then issues out of holes in the pipe. On the other side of the guard is space for second stripe-material, which has its own set of holes.

Striped toothpaste should not be confused with layered toothpaste. Layered toothpaste requires a multi-chamber design (e.g. USPTO 5,020,694), in which two or three layers then extrude out of the nozzle. This scheme, like that of pump dispensers (USPTO 4,461,403), is more complicated (and thus, more expensive to manufacture) than either the Marraffino design or the Colgate design.

Tongue cleaner

2009-08-06T02:26:00.002-07:00

Tongue scraper

Tongue brush

A tongue cleaner (also called a tongue scraper or tongue brush) is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems. In addition, decaying bacteria produce volatile sulphur compounds on the rear of the tongue; these molecules are the main cause of halitosis (bad breath).

tongue cleaner

General

The top surface of the tongue can be cleaned using a tongue cleaner, a tongue brush/scraper or a toothbrush. However, toothbrushes are not effective for this purpose because they are designed for brushing the teeth, which have a solid structure unlike the spongy tissue of the tongue. Ergonomic tongue cleaners are shaped in accordance with the anatomy of the tongue, and are optimized to lift and trap the plaque coating and effectively clean the surface of the tongue. There are many different types of tongue cleaners; they are made from plastic, metal or other materials. Their effectiveness varies widely depending on the shape, dimensions, configuration and quality of the contact surfaces and materials used. The use of the tongue cleaner is recommended before eating, and not after. This prevents the toxic build-up on the tongue from getting swallowed along with food and liquids. A kitchen spoon may also be used to get the same effect.

Historical background

Regarding the origins of tongue cleaning, it is known that they have been used since ancient times in India and China.

Ayurveda, the practice of traditional Indian medicine, recommends tongue cleaning as part of one's daily hygiene regimen, to remove the toxic debris, known as Ama.

In the 19th century, people were also using specially designed, handcrafted tongue cleaners made of sterling silver, ivory and tortoise shell.

Importance of tongue cleaning

Fresh breath

Tongue cleaning is meant to remove some of the millions of bacteria (up to 500 different types ), decaying food debris, fungi (such as Candida), and dead cells, from the surface of the rear of the tongue. Tongue cleaning is generally viewed as the solution for most cases of halitosis, or bad breath. Scientific studies have shown that in approximately 80-95% of cases, bad breath originates in the oral cavity, mainly from material on the rear of the tongue. Research shows that only the rest of about 5-20% of cases originate in the stomach, from the tonsils, from decaying food stuck between the teeth, gum disease, tooth decay, or plaque accumulated on the teeth. Clinical studies have shown that using tongue cleaners on a daily basis has a significant effect on eliminating anaerobic bacteria and decreasing oral malodor.

Better oral hygiene

It is estimated that approximately 70% of the bacteria in the oral cavity thrives on the surface of the human tongue. These microorganisms colonize and multiply on the protein-rich areas of the tongue, and eventually, through the saliva, reach all areas of the mouth including the teeth and gums. These bacteria are considerable contributors to periodontal problems, plaque on the teeth, tooth decay, gum infections, gum recession and even tooth loss.

General health

Oral bacteria are associated with a number of serious systemic diseases.

Cardiovascular problems (heart attack, cerebral stroke),
Pneumonia due to inhaling bacteria present in the mouth,
Premature birth, and low fetus weight at birth time,
Increased risk of diabetes patients,
Osteoporosis of the jaw and generalized,
Infertility problems for men.

Alternative medicine

Cleaning the tongue with an appropriately designed tongue cleaner also massages the tongue. This is an important element of traditional Chinese medicine where the tongue surface is identified as an important reflexogenic zone.

Tongue cleaning improves the sense of taste (because of cleaning the taste buds) and also stimulates the secretions of digestive enzymes.

Who recommends tongue cleaning

Dental professionals
Physicians
Nurses
Halitosis specialists

In the past several years, dental professionals (dentists and hygienists) have emphasized the importance of tongue cleaning as a way to maintain a high level of oral hygiene. In addition, physicians have rediscovered the link between oral health and pathologies of the rest of the body, one which was prevalent in the medical field in the early part of the 20th century. Breath specialists generally agree that the majority of cases of halitosis (bad breath) come from the rear of the tongue, an area that can be cleaned efficiently by using an ergonomically designed tongue cleaner.

Tooth polishing

2009-08-06T02:26:00.001-07:00

A demonstration of tooth polishing.

Tooth polishing is smoothening of tooth surface. The purpose of polishing is to make it difficult for plaque to accumulate on the surface area. Tooth surface is rubbed by rubber cup or brush etc.

End-tufted brush

2009-08-06T02:24:00.002-07:00

Set of end-tufted brushes.

An End-Tufted brush is a modified toothbrush used for cleaning along the gumline adjacent to the teeth. The bristles are usually shaped in a pointed arrow pattern to allow closer adaptation to the gums. An end-tufted brush is ideal for cleaning specific, difficult-to-reach areas, such as between crowns, bridgework and crowded teeth.

Interdental brush

2009-08-06T02:24:00.001-07:00

Set of interdental brushes.

An interdental brush also called an interproximal brush is a modified toothbrush used for cleaning between teeth. It is best used in cases where the gingiva does not fill the space between teeth or when there is orthodontic therapy present. It was invented by John O. Butler Company (Today G.U.M, Sunstar).