Dental plaque

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.

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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.

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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

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

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

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

General

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

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

Origins

Mouth

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

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

Tongue

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

Cleaning the tongue

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

Gum disease

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

Nose

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

Tonsils

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

Stomach

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

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

Systemic diseases

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

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

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

Diagnosis

Self diagnosis and home diagnosis

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

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

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

Professional diagnosis

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

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

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

Home care and treatment

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

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

Mouthwashes

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

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

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

Ancient traditional remedies

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

Halitophobia (delusion halitosis)

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

Scientific research

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

Mouthwash

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

Listerine, an American brand of mouthwash

History

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



Usage

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



Active ingredients

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

OTC mouthwash containing chlorhexidine fromMexico.

Alternative Mouthwash Ingredients

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


Health Risks

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


List of mouthwash brands

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

Geriatric dentistry

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

Temporomandibular joint disorder

Temporomandibular joint

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

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

Signs and symptoms

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

Muscles

TMJ diagram

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

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

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

Temporomandibular joints

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

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

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

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

Teeth

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

Precipitating factors

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

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

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

Treatment

Restoration of the occlusal surfaces of the teeth

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

Pain relief

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

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

Long-term approach

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

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

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

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

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

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

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

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