DENTAL PBL SWEET PAIN Causes of red gums (Aetiology of gingivitis) dental plaque.

. Gingivitis is inflammation of the gingivae, causing bleeding with swelling, redness, exudate, a change of normal contours, and, occasionally, discomfort. Diagnosis is based on inspection. Treatment involves professional teeth cleaning and intensified home dental hygiene. Advanced cases may require antibiotics or surgery. Etiology Most common: poor oral hygiene. o allows plaque to accumulate between the gingiva and the teeth; gingivitis does not occur in edentulous areas. o Irritation from plaque deepens the normal crevice between the tooth and gingiva, creating gingival pockets which contain bacteria that may cause both gingivitis and root caries. o Other local factors, such as malocclusion, dental calculus, food impaction, faulty dental restorations, and xerostomia, play a secondary role. Systemic causes: Commonly occurs at puberty, during menstruation and pregnancy, and at menopause, presumably because of hormonal changes. Similarly, oral contraceptives may exacerbate inflammation. Gingivitis may be an early sign of a systemic disorder, particularly those that affect the response to infection (eg, diabetes, AIDS, vitamin deficiency, leukopenia), particularly if it occurs in patients with minimal dental plaque. o Some patients with Crohn's disease have a cobblestone area of granulomatous gingival hypertrophy when intestinal flare-ups occur. Exposure to heavy metals (eg, lead, bismuth) may cause gingivitis and a dark line at the gingival margin. Severe deficiency of niacin or vitamin C can cause gingivitis.
October 2008 by James T. Ubertalli, DMD
http://www.merckmanuals.com/professional/sec08/ch095/ch095c.html

What is the oral hygiene measure to maintain optimal oral hygiene? Brushing of the teeth and tongue 2 to 3 times daily with regular soft brush or electric toothbrush, regardless of the hematological status. Ultrasonic brushes and dental floss should be allowed only if the patient is properly trained. Patients with poor oral hygiene and/or periodontal disease can use chlorhexidine rinses daily until the tissue health improves or mucositis develops. The high alcohol content of commercially-available chlorhexidine mouthwash may cause discomfort and dehydrate the tissues in patients with mucositis; thus, an alcohol-free solution can use in

such cases. Use of fluoridated toothpaste, fluoride supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish for patients at risk for caries and/or xerostomia. (A brush-on technique is convenient and may increase the likelihood of patient compliance with topical fluoride therapy.)
http://www.guideline.gov/content.aspx?id=14221

Current mechanical and chemotherapeutic approaches to oral hygiene aim to modify the oral microflora to promote healthy periodontal and dental tissues. Current oral hygiene measures, appropriately used and in conjunction with regular professional care, are capable of virtually preventing caries and most periodontal disease and maintaining oral health. Toothbrushing and flossing are most commonly used, although interdental brushes and wooden sticks can offer advantages in periodontally involved dentitions. Chewing sugar-free gums as a salivary stimulant is a promising cariespreventive measure. Despite new products and design modifications, mechanical measures require manual dexterity and cognitive ability. Chemotherapeutic supplementation of mechanical measures using dentifrices, mouthrinses, gels and chewing gums as delivery vehicles can improve oral hygiene. The list includes anticalculus, antibacterial and cariostatic agents. For the population at large to make effective use of these oral hygiene measures, oral hygiene promotion needs to be implemented. Considerations include the role of parents, school and the media for children and the workplace, social environments. nursing homes and trained carers for adults and the elderly. Community oral hygiene promotion must attempt to maximise opportunities for oral health for all and reduce inequalities by removing financial and other barriers. Oral health approaches should be tailored to lifestyles and abilities of children, adults and the elderly in order to enable them to make decisions to improve personal oral hygiene and oral health.
Aust Dent J. 2001 Sep;46(3):166-73. Choo A, Delac DM, Messer LB. http://www.ncbi.nlm.nih.gov/pubmed/11695154

What is the relationship between teeth with sweets? Fermentable carbohydrates and plaque are present at the tooth surface for a minimum length of time for acid to form and cause demineralization of dental enamel. Carbs provide the plaque bacteria with the substrate for acid

production and the synthesis of extracellular of polysaccharides. Not all carbs are equally cariogenic. Complex carbs such as starch are relative harmless because they are not completely digested in the mouth, but carbs with low molecular weight (sugars)diffuse readily into plaque and are metabolized quickly by bacteria. Causes a rapid drop in plaque pH to a level which can cause demineralization to the dental enamel. The plaque remains acidic for some time, taking 30-60 minutes to return to its normal pH. The gradual return of pH to baseline values is a result of acids diffusing out of plaque and buffers in the plaque and salivary film overlying it, exerting a neutralizing effect. Repeated and frequent consumption of sugar will keep plaque pH depressed and cause demineralization of the teeth. The synthesis of extracellular polysaccharides from sucrose is more rapid than glucose, fructose or lactose. Consequently sucrose is the most cariogenic glucose, although other sugars are harmful.
Essentials of dental caries: the disease and its management (third edition), Edwina Kidd, 2005

Although all carbohydrates can cause tooth decay to some degree, the biggest culprits are sugars. All simple sugars, including table sugar (sucrose) and the sugars in honey (levulose and dextrose), fruit (fructose), and milk (lactose), have the same effect on the teeth. Whenever sugar comes in contact with plaque, Streptococcus mutans bacteria in the plaque produce acid. The amount of sugar eaten is of little consequence. The amount of time the sugar stays in contact with the teeth is what matters. Thus, sipping a sugary soft drink over an hour is more damaging than eating a candy bar in 5 minutes, even though the candy bar may contain more sugar.
October 2008 by James T. Ubertalli, DMD http://www.merckmanuals.com/home/sec08/ch114/ch114b.html

Theory of tooth pain due to diet Sweets are not the only culprit. simple sugars that promote tooth decay can also come from starchy foods, especially pretzels, crackers and breads that sick to your gums and teeth.
Judith E. Brown, 2010
http://www.shvoong.com/books/1859370-relationship-carbohydratesteeth/

The most common cause of a toothache is a dental cavity. Dental cavities (caries) are holes in the two outer layers of a tooth called the enamel and the dentin. The enamel is the outermost white hard surface and the dentin is the yellow layer just beneath the enamel. Both layers serve to protect the inner living tooth tissue called the pulp, where blood vessels and nerves reside. Certain bacteria in the mouth convert simple sugars into acid. The acid softens and (along with saliva) dissolves the enamel and dentin, creating cavities. Small, shallow cavities may not cause pain and may be unnoticed by the patient. The larger deeper cavities can be painful and collect food debris. The inner living pulp of the affected tooth can become irritated by bacterial toxins or by foods and liquids that are cold, hot, sour, or sweet, thereby

causing toothaches. Severe injury to the pulp can lead to the death of pulp tissue, resulting in tooth infection (dental abscess). A small swelling or "gum blister" may be present near the affected tooth as well. Toothaches from these larger cavities are the most common reason for visits to dentists
Donna Bautista, DDS http://www.medicinenet.com/toothache/article.htm

Detection of caries clinically & radiographically Caries diagnosis therefore integrates information obtained by: o conversation with patient o biological knowledge o clinical examination of teeth o using caries diagnostic aid VALIDITY - test measures what it is intended to measure; an accurate representation of the state of disease eg. white spot lesion with a matt surface indicates active lesion which has not cavitated RELIABILITY/ REPRODUCIBILITY test may be applied repeatedly with same results eg. the dentist should consistently recognize radiolucent area as caries

1. Prerequisites for clinical - visual diagnosis of caries: o Sharp eyes o Good lighting o Clean, dry teeth (Air/water syringe) o Appropriate use of probe with caution May be use gently, without pressure, to provide information about consistency and texture of surface in a frank carious lesion o Cotton rolls and gauze o Dental mirror o Dental floss 2. Radiograph: Bitewing radiograph- important in diagnosis of proximal carious lesion o The proximal caries lesion appears as dark area (radiolucent) in the radiograph o Large lesion- enamel and outer half of dentine o Clinical lesion is always more advance than appearance on bitewing radiograph o Shortcomings- not able to detect early subsurface demineralisation o Bitewing radiograph can detect demineralisation, cannot diagnose caries activity arrest caries? o Overlapping contact points obscure early proximal lesion Periapical Radiograph Orthopantomograph 3. 4. 5. 6. 7. 8. Fibre-optic transillumination Laser fluorescence method Tooth separation Resting saliva pH of saliva Buffering capacity of

9. Saliva 10. Stimulated salivary 11. flow rate

(lecture notes by Prof Seow)

What is the intervention needed (eg: fillings/proper oral hygiene) Oral health awareness of the students and their schoolteachers was attempted by using educative sheets and pamphlets that were integrated into the school curriculum. Clinical examination was performed to all students in order to assess the high caries risk children together with providing dental health education and sealant application. Follow up was performed in order to evaluate the impact of oral health promotion on these children. Further preventive measures are introduced, such as motivation of regular daily tooth brushing, diet counseling & fluoride supplementation. Even at prenatal phase, using appropriate educative measures for parents, mainly mothers in order to inform them about serious problems such as Early Childhood Caries, was carried out. Strengthening public health programs through implementation of effective disease preventive measures, family awareness and oral health promotion.
Egyptian Dental Journal, 54, 1449:1454, April, 2008. http://www.usenghor-francophonie.org/lettre_info/dentalarticle.pdf

1. Good oral hygiene and regular dental care Brushing before or after breakfast and before bedtime and flossing daily to remove plaque, can effectively control smooth surface decay. Brushing helps prevent cavities from forming on the top and sides of the teeth, and flossing gets between the teeth where a brush cannot reach. Electric and ultrasonic toothbrushes are excellent, but an ordinary toothbrush, used properly, is quite sufficient. Normally, proper brushing takes only about 3 minutes. Floss is gently moved back and forth between the teeth, then wrapped around the tooth and root surfaces in a C shape at the gum line. When the floss is moved with a vertical sliding motion, it can remove plaque and food debris. Initially, plaque is quite soft, and removing it with a soft-bristled toothbrush and dental floss at least once every 24 hours makes decay unlikely. Once plaque begins to harden, a process that begins after about 72 hours, removing it becomes more difficult. 2. Healthy diet People who tend to develop cavities should eat sweet snacks less often. Drinking artificially sweetened soft drinks also helps, although diet colas contain acid that can promote tooth decay. Drinking tea or coffee without sugar also can help people avoid cavities, particularly on exposed root surfaces. 3. Fluoride (in water, toothpaste, or both) Fluoride can make the teeth, particularly the enamel, more resistant to the

acid that helps cause cavities. Fluoride taken internally is effective while the teeth are growing and hardening until about age 11. Water fluoridation is the most efficient way to supply children with fluoride. However, if a water supply has too much fluoride, the teeth can become spotted or discolored (fluorosis). If a child's water supply does not have enough fluoride, doctors or dentists can prescribe sodium fluoride drops or tablets. Dentists may apply fluoride directly to the teeth of people of any age if they are prone to tooth decay. Fluoridated toothpaste and concentrated mouth rinses containing fluoride are beneficial for adults as well as children.

4. Sealants

Sealants protect hard-to-reach pits and fissures (grooves), particularly on the back teeth. After thoroughly cleaning the area to be sealed, dentists roughen the enamel with an acid solution to help the sealant adhere to the teeth. Dentists then place a liquid plastic in and over the pits and fissures of the teeth. When the liquid hardens, it forms such an effective barrier that any bacteria inside a pit or fissure stop producing acid because food can no longer reach them. About 90% of the sealant remains after 1 year and 60% after 10 years. The occasional need for repair or replacement of sealants can be assessed at periodic dental examinations.
5. antibacterial therapy People who are very prone to tooth decay may need antibacterial

therapy. Dentists first remove decayed areas and seal all pits and fissures in the teeth. Then dentists prescribe a powerful mouth rinse (chlorhexidine) for several weeks to kill off the bacteria in any remaining plaque. The hope is that less harmful bacteria will replace the cavity-causing bacteria. To keep bacteria under control, people may use daily home fluoride rinses and chew gum containing xylitol (a sweetener that inhibits the bacteria in plaque).
October 2008 by James T. Ubertalli, DMD http://www.merckmanuals.com/home/sec08/ch114/ch114b.html

Treatment options (difference between composite and amalgam) Silver amalgam (a combination of mercury, silver, copper, tin, and, occasionally, zinc, palladium, or indium) is most commonly used for fillings in back teeth, where strength is important and the silver color is relatively inconspicuous. o Inexpensive and lasts an average of 14 years. o Amalgam can last for more than 40 years if it is carefully placed using a rubber dam and the person's oral hygiene is good. o The minute amount of mercury that escapes from silver amalgam is too small to affect health. Gold fillings (inlays and onlays) are excellent but are more expensive. Also, at least two dental visits are required to permanently place them.

Composite resins and porcelain fillings are used in the front teeth, where silver would be conspicuous. o These fillings are also being used in back teeth. o They have the advantage of being the color of the teeth, but more expensive than silver amalgam and may not last as long, particularly in the back teeth, which take the full force of chewing. o Have the advantage of producing less tooth sensitivity in patients when

compared with amalgam fillings. Glass ionomer, a tooth-colored filling, is formulated to release fluoride once in place, a benefit for people especially prone to tooth decay. o Used to restore areas damaged by overzealous brushing. Root Canal Treatment and Tooth Extraction Bridges, Crowns, and Implants
October 2008 by James T. Ubertalli, DMD http://www.merckmanuals.com/home/sec08/ch114/ch114b.html

Preventive measures at the community level Strongly recommended community water fluoridation and school-based or schoollinked pit and fissure sealant delivery programs for prevention and control of dental caries.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htm

To reduce the incidence of tooth decay, a number of countries have developed campaigns to help inform consumers about cavity-promoting foods. Other countries recommend that sweets be consumed with meals or that teeth be brushed after sweets are eaten.
Judith E. Brown, 2010
http://www.shvoong.com/books/1859370-relationship-carbohydratesteeth/

Educational programs about the risk of smoking, excessive exposure to sunlight, obesity, substance abuse or STD often fail in their objectives and dental diseases are no exception. The Becker Health Belief Model provides some explanation of what perceptions are necessary before patients will comply with a preventive message requiring them to implement a change in lifestyle. o Patient must belief they are susceptible to disease. A common attitude, particularly among younger ppl, is that this wont happen to me. o They should perceive that consequences of getting the disease are sufficiently severe to make them want to take preventive measures. o Must be convinced that the preventive advice given is useful and practical o Benefits gained from the action must be perceived to outweigh the costs of implementing the advice. Costs include not only time and money, but also necessity to give up doing something enjoyable (eating junk food) or necessity to do something they consider unpleasant or difficult (having a mammogram, flossing) o Must feel that the person who gives the preventive advice has credibility.

The manual of dental assisting By Leah Vern Barnett

http://books.google.com.my/books?id=pwbkBUi918C&lpg=PA265&ots=Vyrq7tK1Jb&dq=preventive%20measures%20at%20community %20level%20dental&pg=PA274#v=onepage&q=preventive%20measures%20at %20community%20level%20dental&f=false

Detection of caries clinically and radiographically

Grading for decay: o D1- clinically detectable enamel lesions with intact surfaces o D2- clinically detectable cavities limited to enamel o D3- clinically detectable lesions in dentine o D4- lesions into the pulp Diagnosis of caries require good lighting, dry, clean teeth. If deposits of calculus or plaque are present, the mouth should be cleaned befire attempting accurate diagnosis. Sharp eyes can be used to look for the earliest signs of demineralization. Sharp probe should never be used to detect the tacky feel of early cavitation, because a probe can damage a white spot lesion creating a hole which will subsequently trap plaque. Good bitewing radiographs are essential in diagnosis. In this technique the central beam of X-rays is positioned to pass at right angles to the long axis of the tooth, and tangentially through the contact area. The film is positioned in a film holder on the lingual side of the posterior teeth. The patient then closes the teeth together on the film holder. A beam-aiming device on the holder guides the position of the tube. Caries on free smooth enamel surfaces can be diagnosed with sharp eyes at the stage of the white or brown spot lesion before cavitation has occurred provided the teeth are clean, dry and well lit. Active lesion tend to be plaque covered, close to the gingival margin and may have a matt appearance indicative of surfaces loss of tissue. The lesion may feel rough if the tip of a sharp probe is gently drawn across them. Arrested lesion,mayb have been abandoned by the gingival margin and may have a plaque free, shiny, lustrous

Essentials of dental caries: the disease and its management (third edition), Edwina Kidd, 2005

surface. Sometimes these lesion are brown because the porosities hav absorbed exogenous stain from the mouth.

Relation between pain and sweets

Sugar integrated into the cellular structure of food (e.g in fruit) are called intrinsic sugars. Sugar present in free form (e.g. table sugar) or added to food (e.g. sweets and biscuits) are called extrinsic sugars. They are readily available for metabolism by the oral bacteria and are therefore potentially more cariogenic. Milk contains lactose but is not generally regarded as cariogenic. Cheese and yogurts, without added sugars, may also b considered safe for teeth. Non-milk extrinsic sugars(NMES) are the most damaging sugars for dental health.

Essentials of dental caries: the disease and its management (third edition), Edwina Kidd, 2005