Category Archives: Oral Conditions

Tetracycline Stain

Overview

Tetracycline stain is a condition seen as deep stain in the adult teeth (permanent teeth) caused by tetracycline antibiotics taken during tooth development. The stain is seen as varying degrees of horizontal color bands ranging from gray to gray-brown and even some shades of green, with in varying degrees of intensity; depending on when the antibiotics were taken during tooth development.

Avoiding and correcting tetracycline stains

  1. It is widely known that avoiding the use of tetracycline during any phase of tooth development (during pregnancy, infancy, or early childhood) will prevent the teeth from staining.
  2. In some cases, tenacious bleaching can change the intensity of the tetracycline stain. This requires a dedicated, in office and/or daily routine of home bleaching.
  3. I children, composite veneers can act as a temporary solution until they are full grown and all adult teeth are fully erupted. In adulthood, porcelain veneers or crowns will serve as a more permanent solution
  4. It should be noted that covering the teeth with veneers or crowns is an irreversible procedure that carries with it a much greater expense than tooth bleaching.

Thrush

Overview

Thrush, or oral candidiasis, is a fungal infection that may appear as red, white, or creamy colored areas over the soft tissue. These patches of infection are frequently very painful because of the severe inflammation; inflammation involves: pain, heat redness, swelling and loss of function.

What Causes Thrush?

  • Patients taking antibiotics for other medical issues can cause the natural oral flora to become imbalanced, allowing fungal organisms to overgrow
  • Neglecting to remove and thoroughly clean dentures or partials daily
  • A compromised immune system
  • Debilitation by disease among elderly patients

Treatment usually consists of controlling causes by:

  • Reducing or changing the antibiotic causing the outbreak
  • Thoroughly removing and cleaning dentures and partials every day and keeping them out while you sleep, allowing the underlying tissue to recover
  • Using an anti-fungal when the underlying cause cannot be eliminated
  • Simply eating yogurt has shown to eliminate minor cases of Thrush

Cold Sores (Herpes Simplex I)

Overview

This is a Cold Sore or Herpes Simplex I; note the fluid filled vesicles. This is a highly contagious stage of the outbreak.

This is a Cold Sore or Herpes Simplex I; note the fluid filled vesicles. This is a highly contagious stage of the outbreak.

Cold sores are a recurring viral infection (meaning they come back periodically throughout your lifetime) that appear as fluid-filled blisters (called vesicles) on the outside of the mouth.

How Do Patients Get Cold Sores?

The Primary or Initial Infection

The initial or primary infection is caused by the Herpes Type 1 virus. The virus is highly contagious, and occurs when an infected individual transfers the virus to a mucous membrane or break in the skin. The primary infection usually occurs in childhood or infancy, but it can occur at any time throughout your life. As a primary infection, it can occur without symptoms or present as severe flu-like symptoms of primary herpetic gingivostomatitis such as:

  • Swollen lymph nodes, or lymphadenopathy (limf-ad-en-ah-pah-thee)
  • Fever
  • Severely inflamed gum tissue followed by eruption of fluid-filled vesicles throughout the mouth
  • Foul breath odor
  • Extreme pain and discomfort/difficulty eating
This stage of the Cold Sore appears to be crusting and is less contagious.

This stage of the Cold Sore appears to be crusting and is less contagious.

Recurrent Cold Sores

Following the primary infection, the virus remains in the body and can cause symptoms to recur throughout your lifetime. There is usually a period of time when you are aware that a cold sore is about to erupt called the “prodromal period.” The skin itches and burns with no sign of vesicles.

30% – 40% of all dental patients have recurrent cold sores 3-4 times a year depending on what triggers their outbreaks.1  It appears that stress, excitement, wind, cold, sunburn, the flu, or a cold are all triggers for a recurrence of the cold sores.

It should be noted that cold sores can occur anywhere on your body, although they can more easily occur in mucous membranes (mouth, genitalia). They recur wherever they enter your body. For example, if you scratch a cold sore and your finger has an opening in the skin, the virus could potentially enter the body at this point and recur there in the future. This virus is highly contagious, so care should be taken to avoid touching it until well after a scab has formed. Cold sores are not precancerous.

How Long Does a Cold Sore Last?

Cold sores usually heal in 7-10 days and have the potential to leave a scar that may take months disappear. There are a number of systemic antiviral medications on the market that may help control the recurrent outbreaks. Topical medications may be applied  which may or may not stop the progression of an outbreak. The ingestion of the essential amino acid lysine has also shown to be effective in stopping and/or lessening the severity of an outbreak.

Dental lasers can be used to shorten the duration by stopping the fluid filled blisters from erupting and spreading, creating faster healing.

Cold Sores Misunderstood

The common perception of the cold sore is that they are trivial in nature. These recurrent lesions are highly contagious due to the fluid filled vesicles saturated with the virus.1  Touching the cold sore and transmitting the virus to hands can spread the virus to oneself or others. The cold sore virus is the leading cause of non-impact blindness in the U.S. called Herpes Whitlow; 1.5 million cases are reported each year resulting in 40,000 cases of blindness.2

1. Embil J, Stephens R, Manual R, Prevalence od Recurrent Herpes Labialis and apthous lesions among young adults on six continents, Journal of the Canadian Medical Association, October 4, 1975, Vol 113, p627-630

2. Browning W, McCarthy J, A Case Series, Herpes Simplex Vitus as an Occupational Hazard, J Est. Rest. Dent, 2012 24(1) p. 61-66

The Dental Abscess

Overview

A dental abscess is an infection of a tooth, gums, or the jaw caused by an accumulation of pus and bacteria.

Dental abscesses originate from

  • Tooth Decay: a cavity that has progressed into the nerve chamber, trapping gas and creating inflammation of the nerve inside the tooth
  • Gum disease: deep pockets harbor bacteria that grow under the gum line, trapping gas and creating inflammation
  • Wisdom teeth: trapped bacteria around wisdom teeth that are not completely erupted, but that have a flap of skin partially covering them (the name of this type of abscess is pericoronitis)
  • Trauma: a blow or some type of trauma to the teeth or jaw, causing the death of the tooth

The first two types of abscesses are the result of poor home tooth care and lack of regular dental visits. Untreated tooth decay or periodontal disease will eventually progress to the point where emergency dental care is necessary.

Pericoronitis (peary- core-on-i-tis) occurs when a patient’s wisdom teeth need to be removed but the patient waits until intense pain manifests to schedule the procedure. The flaps of skin over the wisdom tooth prevent your toothbrush from reaching bacteria, allowing them to multiply and spread into the surrounding spaces in your face and around the tooth.

The last type of dental abscess can occur shortly after the trauma (trauma such as a blow to the face) or years later. A patient can have a perfectly intact tooth (no decay, fracture or gum disease) but experience intense pain and swelling indicating that the tooth is dying. The tooth may become loose and extremely tender to touch.

Symptoms of a Dental Abscess

These types of abscesses create pressure with symptoms of swelling and pain. The infection will take the path of least resistance and can progress into the face or neck. The head and neck have spaces where the gas produced by the bacteria can spread (facial spaces), causing swelling. In some cases, the face or neck can also become inflamed over the top of the swollen area, and the lymph nodes under the chin and in the neck can become swollen and tender. In severe cases, the patient can experience fever, chills, malaise, and a general/overall illness.

 

Treatment of a dental abscess:

An abscess caused by the invasion of decay/bacteria into the nerve chamber of the tooth can be treated by one of two procedures:

  • Root canal therapy: depending on the amount of decay or loss of tooth structure, you may have a strong desire to save the tooth.
  • Extraction of the tooth (see Oral Surgery)

Antibiotics and pain medication are often prescribed for this type of infection (different antibiotics are prescribed for different abscesses).

An abscess caused by bacteria infecting deep pockets, found in periodontal disease, can be more difficult to treat. A regime of antibiotics is necessary along with disinfecting the infected pocket. These pockets, once deep down the side of the tooth, can turn and wrap around the root deep under the gum line, making it difficult to disinfect. The use of dental lasers is a highly useful tool in killing bacteria deep in gum disease pockets. Recurrent periodontal abscesses may best be treated by extraction of the infected tooth.

Sometimes a dental abscess can progress rapidly, or the dental patient waits too long to seek treatment, and the infection spreads into the facial spaces, the floor of the mouth, or the neck. At no time should this swelling be lanced or drained unless the infection has “pointed.” This means that the infection has a white head on it like a pimple waiting to be squeezed. Extreme care should be taken when lancing an abscess in the floor of the mouth to avoid damage to the Lingual artery.

 

Receding Gums (Gingival Recession)

Overview

Receding gums or, gingival recession, is a condition where soft tissue or gums around the necks of your teeth shrink away from biting surfaces of your teeth. Gingival recession can be seen on a single tooth or on several teeth, in different areas of your mouth or throughout your entire mouth.

Causes of receding gums

  1. Incorrect tooth position: When a tooth is out of alignment and sits outwardly, away from the inside of your mouth, the bone and gum tissue is thinner than that which is over your teeth that are in alignment. This condition has much to do with two issues:
    • How your teeth grow into your mouth in relation to the space available at the time of emergence. This is why a dentist may recommend a child have an “orthodontic consult” by a dentist who has specialized in straightening teeth. A consult may be recommended as a preventative measure if your general dentist can see that there may not enough room for the tooth to grow into alignment.
    • Your genetic makeup also plays a role in the texture, thickness, and overall ability of your gum tissue to keep your tooth covered. If your tissue is thin and fragile, it will recede more easily than if it is thicker in nature. We all have genetics that determine the color, texture, and thickness of our skin. The inside of your mouth is simply skin with a greater blood supply (thus the pink color).
  2. Clenching and Grinding/ Bruxism: Severe clenching and grinding of teeth can cause gingival fibers (the fibers that hold your gum tissue tight to your tooth) to stretch. If the habit becomes chronic, the fibers can become overly stretched and break which will cause gum tissue to recede. If a tooth is out of alignment and receives a greater than average stress, tissue will thin and tears easily causing recession to happen faster.
  3. Brushing too hard: You may feel that in order to make your teeth clean, a hard toothbrush and/or aggressive brushing is necessary. Excessively hard brushing can contribute to causing gums to recede. When brushing your teeth, always use a soft toothbrush. Since plaque is soft; its removal can be completely accomplished with a soft brush. A hard brush cannot bend and get into the small spaces and indentations around your teeth and can abrade away the soft gum tissue collar around the necks of your teeth. Tooth position and the thickness and texture of your gums, along with the aggressiveness of your brushing, will determine how fast your gums will recede. See Brushing and Flossing.
  4. Time or aging: As we age, our gum tissue naturally recedes a little. As with all other soft tissue changes in the body; the skin in the mouth is no exception. Preventing all of the above will go a long way toward keeping the receding of gums to a minimum.

Correction of receding gums

  1. Orthodontic treatment (see Braces), or having your teeth aligned properly, will help reduce the possibility of gums receding.
  2. Wearing a night guard to reduce the stress on your teeth while you are sleeping and awareness of the habit while awake will help reduce the possibility of gum recession. See TMJ/TMD.
  3. Learn and practice the appropriate method for cleaning your teeth at home. See Brushing and Flossing for more details.
  4. Soft tissue grafting, done by a gum surgeon (see Periodontist), is an outstanding method of repairing areas where your gums have receded.

Dental Plaque

Overview

Dental plaque (sometimes referred to as “biofilm”) is an accumulation of organized bacteria that forms around teeth and matures in 24 hours where it can begin the damage of Tooth Decay and Gum Disease. This film is constantly forming on the teeth, tongue and soft tissue of the mouth, and on any dental devices – such as dentures, partials, or orthodontic appliances – that we place in our mouths. It is made up of bacteria that form on any tooth surface, above or below the gum line.

Most people think that plaque is hard, but plaque is soft and sticky, though removable with a toothbrush, floss, and/or a waterpik. Dental plaque forms and matures to a point where it can harm the mouth in about 24 hours. By this stage, a mature ecosystem has formed, with the most mature and damaging bacteria next to the tooth surface or deep in a pocket next to the area where the gums are attached to your teeth.

Bacterial Plaque: Tooth Decay and Gum Disease

The plaque that forms above the gum line is made up of bacteria that require oxygen to thrive and multiply. These bacteria predominately cause tooth decay. When this type of bacteria is allowed to sit on the tooth for long periods of time, it uses food (predominately sugars) to make acid. The acid dissolves the tooth and creates a cavity called tooth decay.

Dental plaque that forms just under or deep below the gum line is made up of bacteria that do not require oxygen to multiply. When this type of mature plaque is allowed to sit up next to the gum tissue, the beginning stages of gum disease are seen as bleeding, sore, swollen gum tissue.  Eventually the skin attachment gets loose and the pocket deepens (the disease progresses), the bacteria that live deep below the gum line are responsible for the destructive process of bone loss associated gum disease.

When dental plaque forms in a deep pocket (as found in uncontrolled moderate to severe gum disease), brushing and flossing is usually not effective in removing the deepest bacteria. An anti-bacterial mouth mixed in the waterpik water reservoir will reach down the pocket and kill bacteria.

Plaque that is allowed to form and sit for long periods of time can harden into a barnacle-like compound called calculus or tartar  that builds up on a tooth, denture, or any appliance used in the mouth. Although calculus is not harmful, it is covered by live bacteria that is harmful. Once dental plaque has hardened, it is labor intensive to remove, requiring the attention of a dental professional to assure proper removal.

The bacteria that are found in the mouth are “acquired” and from a number of sources. As a newborn, our mouths are considered almost sterile (without bacteria). However, oral bacterial is acquired as we pass through the birth canal, from whoever feeds us as they first test the temperature of our food before placing it in our mouths, through sharing drinks, food, kissing, nail biting…and any other exposure our mouth may encounter. The moist, warm atmosphere creates an ideal environment for them to thrive.

We now know that dental plaque also harbors a variety of viruses, especially the plaque found deep in periodontal pockets.

Oral Cancer

Overview

Oral cancer is a common health risk existing in our population; the dental and medical professions have done little to bring it to the attention of the public. The five year survival rate for oral cancer has not improved much in the past 50 years. The best method for addressing and preventing this troubling condition is early detection and treatment. Routine dental visits and regular oral cancer exams are your best protection.

The oral cancer examination

Examination for early detection of oral cancer and tissue changes should be a regular part of your dental care. At the first sign of any abnormality, the dentist must decide whether to schedule the patient for a follow up exam (to check if there have been changes to the suspected tissue), perform a biopsy or refer to an Oral Surgeon for a second opinion and/or biopsy.

The oral cancer examination may include:

  • Inspection of your hairline, the top of your ears, and over your nose; visual inspection of your scalp if your hair is thinning or if you have bald spots. These areas have had the greatest exposure to sun.
  • Palpation (as defined in the American Heritage Dictionary: to examine or explore by touching) of your lymph nodes in the neck and the area around the back of the neck
  • Inspection and palpation of your upper and lower lips
  • Inspection and palpation of your inner cheeks
  • Inspection of all the gum tissue around all of your teeth
  • Inspection of your entire tongue (the top and bottom); your dental health professional should use a piece of gauze to gently pull your tongue out for inspection of the sides (31% of all oral cancers are found on the lateral borders of the tongue). Palpation of the entire tongue (between 1985 and 1996, 30% of all oral cancers were found on the tongue)
  • Inspection of the floor of your mouth and palpation with two fingers: one inside the mouth under the tongue and one on the outside of the mouth, under the lower jaw. This allows the two fingers to press against one another to feel for any irregularities.
  • Inspection of your hard palate; palpation of your hard palate, feeling for either lumps or areas where bone may be absent
  • Inspection of your soft palate by asking you to say “ah” and watching for your soft palate to move. A mouth mirror should be used to inspect the area behind the soft palate.

Statistics on oral cancer

  1. For all stages of oral and pharyngeal cancer, the:
    • one-year survival rate is 82%
    • five-year survival rate is 59%
    • ten-year survival rate is 48%
  2. The Caucasian survival rate is 55%; the African American survival rate is 31%.
  3. Worldwide, oral cancer is the sixth most common cancer.
  4. In the oral and pharyngeal cancers are responsible for 35,000 cases and 7,600 deaths per year.
  5. About half of these cases are found in the oral cavity; cancer of the oral cavity is more common than cervical and ovarian cancer, Hodgkin’s Lymphoma, or leukemia.
  6. The average age of diagnosis is 63, with 96% of oral cancer being diagnosed after age 40 and 60% after age 65.
  7. Male-to-female ratio of oral cancer diagnosis is 2:1 with a ratio of 1:1 with advancing age.

Highest to lowest area of the incidence of oral cancer

  1. Sides of the tongue (lateral border of tongue)
  2. Lips
  3. Glands that produce saliva (salivary glands)
  4. Under the tongue (floor of mouth)
  5. Inside the cheeks and lips (buccal mucosa)
  6. The gums (gingiva)
  7. The roof of the mouth (palatal mucosa)

Risk factors associated with oral cancer

Highest risk factors: (combine any of these and chances increase by 30%)

  1. Tobacco of any kind
  2. Alcohol (ethanol beverages or mouthwash)
  3. Viruses: HPV16, HCV
  4. Age
    • More than 95% of oral cancers occur at or over age 40
    • More than 83% of oral cancers occur over the age of 55
    • Men 63 years old or older
    • Growing concern for young women in their 20’s
  5. Gender – M: F = 2:1
  6. Ethnicity – African American: Caucasian = 2:1

Secondary risk factors:

  1. Chronic inflammation, trauma (such as an ill-fitting denture or partial)
  2. Immunosuppression/solid organ transplant
  3. Nutritional deficiencies
  4. UV light

9598195

Rhodus, Dr. Nelson L. DMD, MPH (2009). Oral cancer: improving outcomes. Compendium of Continuing Education in Dentistry, 30(8), 486-499.

Rhodus, Dr. Nelson L. DMD, MPH. “Dental Management of Medically Compromised Patients.” Minneapolis, Minnesota. 5 Nov. 2010. Continuing Education, University of Minnesota.

Leukoplakia

Overview

Leukoplakia is a white thickening of the skin on the tongue, gums, floor of the mouth or inside of the cheeks due to some type of chronic (ongoing) irritation. This thickening occurs because of excessive cell growth.

Causes

  • Cigarette or cigar smoking
  • Chewing tobacco
  • Chewing the inside of the cheek
  • Ill-fitting dentures or partials
  • Broken, jagged teeth or failing fillings
  • Orthodontic wires (Braces)

Treatment

In order to treat this oral condition, your dentist must first identify and eliminate the cause. Most often, this means ending tobacco use; changing dental habits; and carrying out the recommended treatment, such as fillings, crowns, and/or replacement of ill-fitting dentures and partials.

The danger with this condition is that it is precancerous and should be monitored every three to six months following its correction. This is not to be confused with Linea Alba.

Leukoplakia is an area (vs. a line) of white, tissue that has been described as a ‘lacey-like looking area. Linea Alba is the thin white line (linea meaning “line” and alba meaning “white”) that runs along the inside of your cheek, demonstrating where your upper and lower teeth come together.

 

Parts of the Tooth

Tooth-Parts1Your tooth is made up of two primary structures: the crown (the part seen in the mouth), and the root (the part of the tooth that is in bone). The crown is covered with enamel, and the root is covered with cementum. The part of the tooth where the crown and the root come together is called the cemento-enamel junction.

Enamel is that part of the tooth covering the crown seen inside the mouth. Enamel is the hardest substance in your body; enamel is even harder than bone. Enamel is made up of prisms (a transparent solid with a triangular base and rectangular sides), allowing light to enter and be reflected back out, a characteristic that makes healthy teeth look pretty, creating a pleasing smile.

Enamel itself has no feeling; there are no nerves or blood vessels attached to the enamel. Any pain felt occurs through an opening in the enamel caused by wear (attrition), a crack, fracture, or decay that exposes the layer under the enamel, called the dentin.

Dentin is found under the enamel and cementum. Passages (call tubules) containing soft fibers run just under the enamel through the dentin tubules to the pulp or ‘nerve chamber’. When stimulated by bacteria (such as those found in a cavity), hot, cold or acidic foods, these fibers stimulate the nerve causing pain or sensitivity in your tooth.

The root is covered by cementum and embedded in bone; which is cushioned by a tissue called the periodontal ligament. Fibers of the ligament run from the cementum covering of the root to the bone. At the end of the root (called the apex), there is an opening where a nerve, artery and vein enter the tooth, running up the roots (root canals) and ending in a space that called the pulp chamber. The nerve brings the sense of feeling to the tooth, the artery brings oxygen rich blood to the tooth and the vein carries oxygen depleted blood away from the tooth.

 

Cracked Tooth Syndrome

Overview

This oral condition is best described as pain that occurs while either biting down or releasing a bite. The crack may or may not be visible and is rarely seen on an x-ray. If it is visible, it is usually seen as a vertical hairline crack; if it is not visible, it can usually be detected with the assistance of a “tooth sleuth”. If your tooth is cracked, it usually causes you to chew your food on the opposite side of your mouth and/or avoid certain foods on the affected side. The diagnosed condition is called Cracked Tooth Syndrome. All teeth have cracks, the majority of which experience no pain.

Symptoms

  • A sharp pain that occurs either when biting down or when the bite is released
  • The pain does not usually linger; rather, it disappears quickly when chewing stops. The pain occurs because the crack is opened when biting, and if fluids enter the open crack when you release the bite, they create pressure against the dentin on the inside of the tooth. Dentin shares a close association with the nerve inside your tooth, and when stimulated, the nerve experiences pain.
  • If you find yourself chewing food on the opposite side of your mouth and/or avoiding certain foods on the affected side
  • The tooth may also be sweet- and temperature-sensitive; this sensitivity is caused when the crack is wide enough to allow sweets and temperature to reach the dentin.

What is a tooth sleuth?

A tooth sleuth is a plastic tool that can isolate and help locate a crack because it isolates the cracked cusp on the biting surface of the tooth. By systematically placing the sleuth on each cusp and asking you to bite down, a dentist can determine if your tooth has a crack. The area where the crack is located can be determined with the aid of a tooth sleuth.

What causes the tooth to become cracked?

  • Bad habits such as chewing on ice, pens, pencils, jaw breakers, etc.
  • The chronic grinding of your teeth
  • A blow to the mouth
  • The weakening of your tooth due to overly large fillings
  • The brittleness of your tooth following a root canal treatment. The pain you experience may be coming from the periodontal ligament because the tooth itself is dead. If the crack extends to the area of the periodontal ligament, your dentist may recommend a crown immediately.
  • Misaligned teeth receiving more stress than is acceptable during chewing

Treatment of cracked tooth syndrome.

  • The treatment of a cracked tooth depends on the size of the crack and the ability of the dentist to eliminate the problem causing the crack
  • Minor cracks may be treated with desensitizers, but without eliminating the cause, the crack will probably recur and worsen
  • Typically, the placement of a crown will keep the crack from opening and will alleviate the pain
  • There is no way of knowing if the crack extends below the bone level; only time will tell once the crown is placed. If the problem persists over time following crown placement, you may be experiencing a complete vertical fracture and your tooth may not be salvageable.

The most important thing to remember is that most dental expense is caused by putting dental visits off. Visit your dental professionals regularly to catch problems early and keep expense down.