Compendium on Dental Health Book Compiled by Dr. Col. M c sharma Introduction



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Compendium on Dental Health
-Book Compiled by Dr.Col.M C Sharma

Introduction

Dental diseases in general are diseases of civilization. More civilized the society, and advanced the nation, general dental problems are higher. This can be attributed directly to dietary habits. Consumption of food in its natural form is what the teeth were actually meant for by nature, but since we have modified natural food into various forms to suit our culinary delights, generally all types of food that we consume have become sticky in nature. Therefore after chewing, wherein no food should stick to the teeth, this sticky food adheres to the teeth, and is the root cause of majority of dental problems. Dental decay (caries) and periodontal (gum) disease are among the two most common diseases afflicting mankind, especially in the so-called advanced nations.


Higher the standard of living, more likely it is for tooth decay to occur, since there is a gross mismatch between eating habits and hygiene habits. Eating habits are pretty modern but hygiene habits are primitive. Therefore for optimum oral health, there should be harmony between eating and hygiene habits. Dental caries and periodontal disease are the result of bacterial action, in the plaque, which collects on the teeth and gums.
If it is possible to cleanse the mouth completely of the bacterial plaque and maintain it that way, there would be low incidence of tooth decay or any other gum problems. Dental diseases are not considered to be life threatening, it is more about quality of life and therefore attitudes on the part of government and public are of a

different nature. However, the cost of dental disease in pain, suffering, treatment and loss of work is enormous. Measures to reduce or eliminate dental problems would result in a vast benefit to the population.



Bad Breath

Many people worry about bad breath, either, their own or someone else’s. The advertising media have made much of the social stigma arising from ‘offensive breath’ to their own advantage. Bad breath or halitosis may indicate a dental problem, but this may not always be the case.
Causes
The odour may be caused by factors in the mouth or by changes occurring in other parts of the body.
Local Causes:


      • Decaying food particles on or between the teeth.

      • A coated tongue covered by bacteria.

      • Unclean dentures.

      • Smell of tobacco.

      • Alcohol.

      • Gum diseases with pus production.

      • Healing wounds after a surgery or extraction.


Other Causes:


  • Running nose with infected nasal air passages

  • Acute inflammation of air spaces present within the facial bones (often filled with pus)

  • Infected Tonsils.




  • Many waste products broken down from food and drinks are excreted through the lungs and this applies to alcoholic drinks as well as pungent foods like onion, garlic etc.




  • Diabetes in which the patient has a sweet acetone breath.


Bad breath is not a disease, it is a symptom, which indicates the presence of disease either within the mouth or away from the mouth. Odours, which may appear unpleasant to many, may not be the same to some e.g. some people are accustomed to the scent of garlic, a scent which many people find obnoxious.


Bleeding Gums

Bleeding gums is among the most common conditions affecting the mouth. The Chinese probably noticed bleeding gums as early as 2500 BC. They termed the associated diseases as “Ya-Kon” which means diseases of soft tissue surrounding the teeth. This problem still continues to affect us even with so many modern facilities available in the field of oral care.


Causes
1. Long standing infection of gums because of poor maintenance of the teeth, such as inadequate brushing or failure to rinse the mouth after meals results in a thin layer of food and bacteria covering the tooth surface. This bacterium is the chief cause for the infection. The gums during the stage of infection become soft, spongy and swollen. Trauma to the gums by hard brushing or tooth picking with sharp objects also results in gingival bleeding.
2. Bleeding can also be due to injury of the gums by any sharp food item e.g. fish bone.
3. Hot food and chemicals can cause burning of gums, further resulting in bleeding. For e.g. Some people still follow the practice of placing pain relieving tablets on the gum adjacent to the painful tooth, which invariably causes burns. This is not a good practice.

4. Certain rapidly spreading infections can damage the blood vessels of the gums resulting in bleeding. One such disease is ANUG or Acute Necrotizing ulcerative gingivitis.


5. Deficiency of Vitamin C causes problems with the blood vessels, hence causing bleeding in the gums. Ancient sailors were known to suffer from this problem until someone came up with the bright idea of stocking the ships with oranges during travel. As we know oranges are rich sources of Vitamin C. Guavas are the richest source of Vitamin C.
6. Certain general illness of the body listed below can also precipitate gingival bleeding.
a. Allergic reaction.

b. Decrease in number of cells called platelets. These are cells, which join together to form a plate that blocks the bleeding from an injured vessel.


c. Failure in Blood clotting mechanism due to deficiency of a few important components.
d. Cancerous condition called leukemia.
e. Certain drugs such as aspirin and anti-coagulants, which prevent the normal clotting mechanism of the blood.
Bleeding gums are an indication of a slowly progressing disease of the gums, which may further involve the bone supporting the tooth and ultimately result in tooth loss.

Frequently Asked Questions
Is bleeding gums a serious problem?
Yes, bleeding gums is a serious problem. It is either indicating the beginning of the destructive process involving the supporting tissue around the tooth or some serious underlying systemic problems, which could be fatal.
Is there any medication for bleeding gums?
Liquid solutions are available over the counter at the chemist, which can be self administered by the patient. When applied over the gums, it either stops or reduces bleeding. But long lasting result is obtained only by consulting a dentist and treating the cause.

Swollen Gums
(Gingival)

Change of gums from a thin, well-adapted, continuous covering around the teeth to a thick swollen red mass, may not only appear unsightly, but also acts as a platform for further destruction of healthy teeth and supporting bone.
Causes
1. Most common cause is infection of the gums, by a thin covering of food and bacteria on the tooth surface called “Plaque”. The bacterial content of this plaque trigger a response from the gum, which results in a swelling.
2. Due to certain normal conditions such as pregnancy and puberty, there is swelling of the gums. This swelling is an abnormal response to the normal bacteria present in the mouth. The abnormal response is a result of hormonal changes or variation seen during the above-mentioned conditions.
3. Certain disease or deficiency condition may also result in swollen gums, like


4. Certain drugs used by the patient may result in increased size of the gums as a side effect for example.




  • Phonation used in epileptic fits.

  • Nifidipine used for blood pressure.


Symptoms
1. Pain may or may not be present.
2. If the cause is infection, then the initial stage is indicated by the presence of bright red gums. As the infection progresses the color changes from red to bluish red to deep blue.
3. The gingiva becomes soft and spongy, rarely may it become thickened due to formation of scar tissue.
4. Bleeding of the gingiva is another common symptom in the advanced stage.
5. Swelling caused by drugs is usually very hard and thick. The gingiva will become swollen even after treatment of the swelling. The swelling occurs only when the drug is administered for a certain period of time.





Treatment


  • In case of swelling due to inflammation, good care of the teeth and the gums by proper and timely brushing and   use of mouth washes can reduce the swelling.




  • If collection of plaque or food debris is in large amount then professional help is required to

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remove the deposits commonly called tarter,   which is firmly stuck to the teeth.


  • If swelling is due to drugs, stoppage of the drug under medical supervision automatically causes a reduction of swelling.




  • In case of swelling due to general illness, correction of the health problem usually results in an improvement.




  • If swelling is a tumor then surgical removal is the only answer.





Frequently Asked Questions
Can a swollen gum cause any discomfort?
It is usually associated with a mild constant gnawing pain, or may cause no pain at all. The swelling may hamper normal brushing, resulting in increased accumulation of bacteria and hence cause more inflammation and destruction of gum tissue.


Thumb Sucking
Thumb sucking in children has always caused embarrassment to many parents. Parents are more concerned over the social embarrassment caused by this habit rather than the actual physical damage caused by it. This habit as it appears to many parents not only causes abnormally arranged teeth but also implicates the mental state of the child.
Causes

Thumb sucking can either be a non-compulsive act or a compulsive oral habit.


Non-Compulsive act :
As children grow, they pick up or drop habits depending on its acceptability. These habits are usually called non-compulsive habits or acts. Thumb sucking can be one such habit, which can be seen from birth to the age of 16. On an average most of the children stop this habit by the age 4. There are some children, however, who can continue the habit to as late as 12-15 years. In these children, thumb sucking is usually a way to relieve the frustration of hunger.
Compulsive Act:
Thumb sucking can be called compulsive when it has acquired a fixation in the child to the extent that he retreats to the practice of this habit whenever his security is threatened by events, which occur in his world. Unlike the non-compulsive habit, the child tends to suffer from increased anxiety when he attempts to correct the habit.

The habit becomes his safety valve to release emotional pressure, whenever it becomes, too much to cope with. Lack of love and affection by the parents towards the child plays a major role in making the child emotionally insecure and thus making him resort to habits like thumb sucking. If the habit is discontinued before the permanent teeth eruption, it can be considered harmless. Continuous thumb sucking leads to many ill effects like:

1. Displacement of the child’s permanent teeth due to the uneven forces placed on the teeth by the thumb.
2. The upper and lower front teeth may not approximate with each other.
3. The upper front teeth may flare out.
4. The open bite or lack of approximation of upper and lower front teeth may result in speech difficulties during pronunciation. As a result of the flared out or protruding front teeth the child may     end up fracturing these teeth more often. Protruding and uneven teeth change the facial appearance. This can cause an inferiority complex in the young mind.

Diagnosis
Any child above the age of 4 with protruding anterior teeth may be affected by thumb sucking. A detailed history about the habit is very helpful. The frequency and duration of this habit can help in evaluating the extent of the habit. The thumb used by the child normally appears to be very clean compared to the other finger.


Treatment
It can be treated by the following methods.
1. Psychological Method:

The child is guided by the dentist and parent to consciously put an end to the thumb sucking habit over a period. This is possible only if the child is psychologically willing and wants to stop the habit. Children often combine thumb-sucking habit with other secondary habits such as hair pulling or nose probing. Frequently making the secondary habit impossible to perform can break the primary habit. It is very important not to criticize the child. The child needs a lot of support and affection. He should be told about the ill effects of sucking the thumb to reinforce his determination to stop thumb sucking.


2. Extra oral method: 
a. Painting the child’s thumb or finger with an unpleasant tasting substance.
b. Tapping the thumb with plaster so as to prevent thumb sucking.
The above-mentioned methods will succeed depending upon the attitude of the parent. The parents should in some way reward the child for “growing out of the habit” during the procedure both by their action and by a small token prize.
This will make a deep impression on the child and orient him towards completely breaking the habit. The parent should also be warned that there is always the

Possibility that a more deleterious habit will spring up in its place if the present one is suppressed.


3. Intra oral methods:
This is done by fabricating appliances, which are then fitted into the mouth of the child by the dentist. They are normally viewed as punishment devices by the child there by sometimes producing severe emotional disturbances. If the appliances are going to convert a happy youngster into a nervous child overnight, it is not worth it.
There are other oral habits, which should be brought to the notice of the child’s dentist. These habits are lip sucking, tongue thrusting, nail biting, mouth breathing and bruxism (Clicking of teeth).
All the above-mentioned habits will definitely take its toll on the teeth. Therefore, early identification and treatment of these habits is necessary to ensure a good set of teeth and a lovely smile.

Frequently Asked Questions
Is thumb sucking a natural habit?
Yes, thumb sucking is a natural habit until the age of 4. Continuation of the habit beyond the age of 6 will result in mal-alignment of teeth. Most children give up this habit by themselves, but in cases where this doesn’t occur a dentist should be consulted.


Is there any other effect of thumb sucking other than that on the teeth?
Sucking on a dirty finger can make the child prone to infection, as during this stage children normally tend to play in mud.

Oral Cancer
Cancerous growth occurring within the mouth is known as Oral Cancer. The oral cavity includes the mouth and all the structures within it, such as the tongue, teeth, gums, jaws etc.
Cancer is an abnormal disorganized growth of cells in the tissue of a person. Cancer cells keep on multiplying without obeying the body’s command to stop. This abnormal growth of cells destroys the normal structure and the function of the affected tissue and the body in general. Males are twice as more prone to oral cancers than females.
Causes :
Cancer in the mouth is a slow and progressive disease.
The factors responsible for oral cancer are :


  1. Tobacco.




  1. Alcohol.




  1. Syphilis (a sexually transmitted disease caused by a bacteria).




  1. Nutritional deficiencies.




  1. Virus infection.




  1. Excessive exposure to Sunlight.

7. Other miscellaneous factors are trauma, heat, irritation from sharp teeth, poorly restored fillings and   ill-fitting dentures.


Oral cancer may initially present without any symptoms. Patients are most often identified only after a significant progression of the disease. Discomfort is the most common symptom that compels a patient to seek medical care. Patient may present with any of the following symptoms:


  • Awareness of a mass present or growing within the mouth.




  • Difficulty in swallowing.

  • Toothache.

  • Pain in the ear.

  • Limited mouth opening.

  • Excessive bleeding which is not seen commonly.

  • A non-healing ulcer in the mouth.

  • Swelling on the gums interfering with the seating of the dentures.

Majority of oral cancers involve the tongue, the posterior region of the oral cavity and the floor of the mouth. The lips, gums, the under surface of the tongue and the palate (bones separating the mouth from the floor of the nose) are less frequently involved.

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Warning signs of Oral Cancer
Certain pre-cancerous lesions occurring in the oral cavity may indicate the person’s susceptibility to cancer. These lesions can be in the form of:


  • White patches on the mucous membrane covering the oral cavity and along the lateral border of the tongue, which cannot be removed by rubbing the affected area.




  • Red patches seen on the mucous membrane lining the mouth and the tongue.




  • Increase in fibrous content of the mucous membrane lining the cheek, which presents itself as thick fibrous bands running along the inner aspect of the cheek. Commonly seen in betel nut chewers. This condition results in inability to open the mouth.

All the above lesions cause a burning sensation on eating spicy food.


Treatment
The principle objective is to cure the patient of cancer. The choice of treatment depends upon factors such as cancer cell type, amount of changes in the cell, size and location of the cancerous growth.
Surgery or radiation is used with curative intent in treatment of cancer. Chemotherapy (Medicines) is used as an additional form of treatment. In an early lesion either surgery or radiation as a form of treatment would suffice. But in an advanced condition, a combination of both surgery and radiation is required.
There is rarely a second chance available for cure. Hence the initial approach of treatment is critical. The survival rates after early detection and treatment of cancer have been noted to be 70%. Chemotherapy (Medicines) is a weak substitute for the above-mentioned treatment.
Tobacco consumption either in the form of smoking or chewing is an important factor in the development of oral cancer. About 97% of oral cancer victims are known to be associated with tobacco either in the form of smoking or chewing. Pipe smoking and cigar smoking have been known to increase the risk levels by many folds. Among the various habits associated with tobacco, tobacco

chewing is known to cause oral cancer more rapidly than any of the other habits. This is because of the direct and repeated contact of the tobacco with the mucous membrane of the oral cavity.




Surgery
If the lesion is small then there are usually no side effects, but if the lesion is large then it may require the removal of the affected structure resulting in the speech defects difficulty in swallowing and also facial deformities. Such patients will require specific rehabilitation by a team approach preferably in an institutional setup.
Radiation therapy
During and after radiation therapy the patient develops mouth sores. The patient also suffers from reduced secretion of saliva, which causes difficulty in swallowing and makes the patient more prone to teeth decay and other forms of infection.
Chemotherapy
Side effects depend on the kind of drug used. The usual side effects are loss of hair, ulcers in the mouth and in the stomach, reduced resistance to infection, loss of appetite, nausea, vomiting, and lack of energy.
Frequently Asked Questions
Do all betel nut or tobacco chewers get oral cancer?
Betel nut and tobacco chewers are definitely more prone to oral cancer than those who do not have this habit, but there are also other contributing factors such as genetics, diet, environment and the person’s immune system.


Will stopping the habit improve the condition?
There are certain lesions seen frequently in the mouth of betel nut and tobacco chewers. These lesions precede oral cancer. If these preceding lesions are identified in time, then stopping the habit will definitely improve the lesion or maybe even cure it.
Is pain an early symptom of Cancer?
Not always. Pain is usually a late symptom of cancer. People often think that persistent pain such as headache or constant pain in the region of the face means cancer, but this is rarely the case. However pain should not be ignored.
What are the side effects of treatment?
There are side effects to all forms of treatments involving oral cancer.

AIDS

(Acquired immuno deficiency syndrome)
Oral health : The First Reflector of AIDS
AIDS has taken on massive proportions in modern times. It is estimated that over 15 million people are suffering from the disease and many more are harboring the dreaded Human Immunodeficiency Virus (HIV). Besides creating havoc on the body's immune system, the AIDS virus also causes serious damage to the mouth and the surrounding structures. The mouth as we know is a hotbed of all kinds of microorganisms, some of which are quite normal to the area. But under immuno compromised conditions, these normal microorganisms start to cause irreparable damage to the area. Besides, the teeth themselves, lips, tongue, gums and cheeks are affected by AIDS.
What actually happens in AIDS?
The basic defect in AIDS is that the virus destroys the immune system of the affected individual. In fact, it is not as much the virus as the individual who is responsible for all the illnesses suffered as a result of AIDS. All that the virus does is rendering the immune system impotent, thereby affecting the individual's capacity to ward off common infections. This is why pneumonia happens to be the leading cause of mortality in AIDS. One thing to be noted is that being HIV-positive does not necessarily mean having AIDS. Full-blown AIDS occurs only after certain immune functions are completely destroyed by the virus.

AIDS and the mouth
Mouth is the first area where the AIDS virus presents striking signs. Some of the conditions exclusively associated with AIDS are :


  • Oral Hairy Leukoplakia

  • Oral Candidiasis

  • Kaposi's Sarcoma

  • Oral Pigmentation

  • Gum Disease


Frequently Asked Questions
Which doctor should I see if I have AIDS?
Your physician is the first doctor that you should consult. In case the oral symptoms are causing much distress, you can consult your dentist for symptomatic relief of the same.
Does Oral Hairy Leukoplakia occur in any other condition?
No. Till date, OHL has been exclusively associated with AIDS and is an indicator that the individual is on the road to developing the full-blown version of the same.
What about Candidiasis?
Candidiasis is basically a fungal infection and in cases where no other reason for its occurrence can be discerned, it is almost always due to AIDS.
What precautions must be taken to avoid gum disease in AIDS?
It is said that a clean tooth never decays. Hence, the best way to prevent the impact of gum disease in AIDS is to keep the teeth as clean as possible. Brush after meals and use an anti-bacterial mouthwash to rinse twice a day.

Dental Caries
(Cavity)

Dental caries is the destruction of the tooth structure which subsequently forms a hole / cavity in the tooth. The dentist removes this infected part of the tooth and fills it with a suitable filling material. These cavities are prepared in a scientific and a principled manner in order to achieve a strong and a long lasting filling.
The main idea of preparing a cavity is to remove the infected portion of the tooth so as to prevent the further spread of decay. A cavity is prepared using high speed drilling equipment, which is controlled by the dentist. Patient may not have any discomfort initially but as the drill bit moves closer to the center of the tooth (where the nerves are located), the patient begins to experience sensitivity. This can be avoided if tooth is anesthetized, which of course means the patient having to take an injection. If the cavity prepared is very deep, a layer of medicated cement is used to line the floor of the cavity to help in healing of the tissue. In case a metal based filling material is used, a cement base is given. This base is nothing but a coat of cement, lining the floor of the cavity. The base insulates the tooth from sharp variation in temperature, caused by the increased thermal conductivity of the metal filling. The term cement, which is frequently used, is a mix of a chemical powder and liquid. This mix, which is initially soft, turns hard in a few minutes. For a cavity which is not very deep, a cement base may not be required.

Filing of a prepared cavity depends upon a lot of factor such as:


  • Site : for an anterior tooth a metal filling may not be acceptable, so a tooth colored material is used.




  • Function of a tooth: A posterior tooth might require a very strong filing to withstand the forces produced while chewing food.




  • Amount of remaining tooth structure: Too much of a hard filling material and very little amount of remaining tooth structure can cause the fracture of the tooth.




  • Type of material used to fill the opposing tooth : When two different metals are used to restore two opposing teeth, small amounts of galvanic currents are produced which can be painful for the patient.


Filling materials can generally be of 2 types


  • Tooth colored - Glass inomer cement, composites etc.




  • Non tooth colored – Silver Amalgam, Gold Each material has its own advantages for e.g. Amalgam is much more strong & tougher than the tooth colored composite hence ideal for posterior teeth, where as composite filling material require very little cavity preparation and hence saves a lot of tooth cutting thereby preserving as much natural tooth structure as possible.

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